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Class JxlMJ 
Book ^^3 



EXERCISE ^s 



IN 



EDUCATION AND MEDICINE 



BY 

R. TAIT McKENZIE, B. A., M. D. 

Professor of Physical Education and Director of the Department, University of Pennsyl- 
vania ; Fellow of the College of Physicians of Philadelphia and of the American 
Academy of Physical Education ; President of the Society of Directors of Physical 
Education in Colleges ; Sometime Lecturer in Anatomy and Medical Director of 
Physical Training at McGill University; Lecturer in Artistic Anatomy, Montreal Art 
Association, Harvard Summer School, and Olympic Lecture Course, St. Louis, 1004 



IVITH 346 ILLUSTRATIONS 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 

1909 



Copyright, 1909, by W. B. Saunders Company 



PRINTED IN AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 



/ 



CU.A, 243680 
JUL 14 r9Qg 



T^V^ 



^^^ 



"Man is the sum of his movements." — F. H. Robertson. 

"That which those who winnow wheat do for it, gymnastic exercises accom- 
plish in our bodies for us." — Solon {Dialogues of Liuian). 

"It is to be considered that some medicines may require exercise in oider 
to enhance their virtues or remove some inconveniences attending their operation. 
Exercise, in such cases, is like the just and exact incubation to the egg ; that 
which animates the drug and gives it power to produce the desired effect." — 
Fuller. 



Digitized by the Internet Archive 
in 2011 with funding from 
The Library of Congress 



http://www.archive.org/details/exerciseineducat02mcke 



PREFACE 



The followins: pages are addressed to students and practi- 
tioners of physical training; to teachers of the youth; to stu- 
dents of medicine and to its practitioners, with the purpose to 
give a comprehensive view of the space exercise should hold in 
a complete scheme of education and in the treatment of abnor- 
mal or diseased conditions. 

The recognition of physical education by teachers has been 
retarded by dabblers and self-elected professors of one or other 
systems, whose extravagant claims have done much to obscure 
the real educational value of neuromuscular training; for the / 
result of physiologic research in the growth and development 
of the nervous system is just beginning to be applied in the 
classification and design of exercise, to harmonize it with the 
conclusions of proved science. 

Exercise has so many points of contact with education, it is 
so intricately related to mental, moral, and social training, each 
of which alone is so partial and incomplete, that the progressive 
educationalist is now compelled to study its bearing on all three. 

It is of vital importance that the student of physical training 
should have a broad and catholic foundation on which to build 
the structure of his experience, and that he shall consider and 
balance the merits and limitations of systems and ideas coming 
from diverse lands. The normal schools and colleges of physical 
training are lengthening their courses and broadening their cur- 
riculum to meet this increasing need, and, with more thoroughly 
educated instructors, there will be less seen of a certain super- 
ciliousness with which the whole subject is regarded by some 
otherwise well-informed physicians. 



12 PREFACE 

The progress of medxal science has been most notable in the 
great questions of national health and prosperity involved in the 
feeding, housing, and exercise of the people. School boards are 
appealing for medical inspection of the children to discover cor- 
rectable defects and to prevent the spread of disease. The 
pern cious influence of indoor life on growth has been proved, 
and measures arc now taken to remedy it by exercise and play; 
city slums are replaced by playgrounds, colleges and universities 
are placing on their curriculum instruction in physical education, 
both practical and theoretical, since the necessity for exact know- 
ledge of the physical characteristics which differentiate the child 
from the youth, and both from the adult, has become patent to 
the thoughtful physician whose advice is so constantly asked. 

Exercise and massage have been used as remedial agencies 
since the days of ^Esculapius, but definite instruction in their use 
has seldom been given to medical students. Perhaps a certain 
laziness which is inherent in both patient and physician tempts to 
the administration of a pill or draught to purge the system of what 
should be used in normal muscular activity, but there is a wide 
dearth of knowledge among the profession of the scope and 
application of exercise in pathologic conditions, and the neces- 
sity of care in the choice and accuracy of the dosage will be 
emphasized throughout the second part of this book. 

I have endeavered to acknowledge in the text the sources 
from which facts are culled, but I must especially acknowledge 
my indebtedness to the inspiring friendship of my colleague, 
Dudley A. Sargent, to E. M. Hartwell, from whose classic re- 
ports to the U. S. Bureau of Education, much of the historical 
data relating to gymnastic systems was obtained; also to 
Fred. E. Leonard, of Oberlin, whose historical researches on 
! physical education have been mined with rich results. The 
studies of Luther Halsey Gulick, on the development of plays 
among children, and G. Stanley Hall's work on Adolescence 
have been most serviceable sources of inspiration, while the chap- 
ters on exercise for the blind, deaf, and mental defectives have 
been founded on the work of Edward Allen, Grace Green, 



PREFACE 13 

and Maurice Barr, in their respective specialties. In the section 
on medical treatment I have striven to credit other workers in 
the field with the contributions they have made, but much of it 
is my own experience, gathered from a special practice in the 
application of exercise. 

I trust that this book may help to place before the profession 
this Cinderella of the therapeutic family in her true character. 

R. T. M. 

Philadelphia, Pa. 
July, 1909. 



CONTENTS 

PART 1 

EXERCISE IN EDUCATION 

CHAPTER I PAGE 

The Definition and Classification of Exercises 17 

CHAPTER II 
The Physiology of Exercise 29 

CHAPTER III 
Massage and Passive Motions 45 

CHAPTER IV 

Exercise by Apparatus 56 

CHAPTER V 
The German System of Physical Training 74 

CHAPTER VI 
The Swedish System of Gymnastics 86 

CHAPTER VII 
The "Soft Business of Japan," the "Gospel of Relaxation," and 

the " Doctrine of Contraction " 104 

CHAPTER VIII 

Age, Sex, and Occupation 122 

CHAPTER IX 
Playgrounds and Municipal Gymnasiums 137 

CHAPTER X 

Physical Education in Schools 158 

CHAPTER XI 

Physical Education in the College and University 174 

CHAPTI-.R Xn 
The Physical Education of the Blind and the Deaf-mute 194 

CHAPTER XIII 

Physical Education of Mental and Moral Defectives 210 

IS 



l6 CONTENTS 

PART II 

EXERCISE IN MEDICINE 

CHAPTER XIV PAGE 

The Application of Exercise to Pathologic Conditions 222 

CHAPTER XV 
Flat-foot and its Treatment 236 

CHAPTER XVI 
The Cause and Treatment of Round Back, Stooped and Uneven 

Shoulders 250 

CHAPTER XVII 
Scoliosis — Its Causes, Varieties, Diagnosis, and Prognosis 271 

CHAPTER XVIII 
The Treatment of Scoliosis 291 

CHAPTER XIX 
Exercise and Athletics as a Factor in Diseases of the Circulation. 315 

CHAPTER XX 
The Exercise Treatment of Diseases of the Circulation 325 

CHAPTER XXI 
Obesity — Its Causes and Treatment 346 

CHAPTER XXII 
Other Disorders of Nutrition 356 

CHAPTER XXIII 

Exercise in the Treatment of Nervous Diseases 370 

CHAPTER XXIV 
The Treatment of Locomotor Ataxia by Exercise 382 



INDEX 395 



EXERCISE IN EDUCATION AND MEDICINE 



PART I 

EXERCISE IN EDUCATION 



CHAPTER I 



THE DEFINITION AND CLASSIFICATION OF 
EXERCISES 

The term exercise, as here employed, comprises all movements, 
voluntary or passive, including manipulations by the hand of an 
operator or by a machine, designed to act on the muscles, the blood- 
vessels, the nervous system, the skin, and the abdominal organs. 

This wideness of definition is necessary to cover its application 
and its efi&cacy as a medicinal agent. 

It naturally falls into the two main divisions given by Plato — 
active and passive. 

1. Active exercise requires a definite exertion of the will 
power, whether in its more complicated form of games and gym- 
nastics, or in simple duplicate directed movements with assistance 
or resistance by the hands of an operator or by a machine. 

2. Passive exercise does not require any exertion of will 
power. The various manipulations of massage, by means of the 
hands, or by the machines of Zander and others, by which con- 
tracted ligaments or muscles are stretched and nourished, local 
nutrition improved, nerves stimulated, and the abdominal organs 
affected, are restful rather than exhausting to an overwrought 
brain. 

Active exercise may be subdivided into, first, those involving 
a single effort of one or more muscle groups, such as lifting a 
weight or performing a feat on the parallel bars; and, second, 
2 17 



15 EXERCISE IN EDUCATION AND MEDICINE 

exercises of endurance, consisting of motions rhythmically repeated 
without great muscular expenditure for each one, and depending 
for their effect upon continuous repetition. 

Exercises of effort may be more or less violent in character or 
compound in motion, each one starting from and ending with rest. 
They are in endless variety, from simple movements of lifting and 
throwing, to the complicated combinations on the parallel bars 
and horizontal bar. In them the element of skill plays a leading 
rdle, and what would be a mild exercise for the expert may be a 
severe strain to the beginner, whose inaccuracy means the clumsy 
employment of many muscles that help little in its accomplish- 
ment, the contraction of some groups actually retarding success. 
Even in the accurate performance of an apparently simple move- 
ment, the distribution of muscular effort is wide, and increases 
tremendously with the difficulty of the feat. In pushing a heavy 
dumb-bell to arm's length above the shoulder, the extensors of the 
elbow-joint are the ones usually considered, but the entire muscular 
system shares in the effort. The grasping muscles of the hand 
are required, also the muscles that raise the shoulder and 
rotate the scapula. These are attached to the spine and ribs, 
which in turn must be supported by the pelvis, steadied on the 
hips, while the balance of the body is preserved by the muscles of 
the thigh and legs. 

A single, simple effort, then, may give rise to fatigue of more 
than the muscles most obviously employed. 

Education should be directed to teaching skill in the per- 
formance of such movements — skill that tends to economize the 
amount of effort required — for it is the common experience of shot- 
putters to find that their record performance is accomplished 
with the greatest ease, owing to the smooth, accurate application 
of group after group of muscles at the proper time; and the perfec- 
tion of balance and speed of the body's movement. 

However skilful the performer may be, the whole muscular 
system participates in any violent exercise of effort. During 
the intense concentration so necessary for success, the chest-walls 
are fixed; the glottis is closed, the lungs acting as an air cushion 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 



19 



for the surrounding cage of ribs and diaphragm; all the 
muscles of the trunk are steadied, and when the effort is made 
there is an explosive discharge of nervous energy, the intensity 
of which is mirrored in the muscular rigidity of the athlete's 
face. 




Fig. I. — The typical face of violent effort seen in sprinting, hammer-throwing, or spurting 
in a distance race (modeled from life by the author). 

The face of such a man will show a general converging of the 
lines to the root of the nose, with transverse wrinkles over the 
bridge. The frowning brows are drawn down and the eye is 
narrowed to a mere slit. The outer angle of the eye shows the 
"crow's feet " accompanying all violent action of the muscles that 
close it. The nose and upper Up have a snarling expression, the 
nostrils are distended, and the lower lip is drawn tightly across the 
clenched teeth, except at the angles of the mouth, where there 
are little pouches caused by the pulling of the platysma, which 



20 EXERCISE IN EDUCATION AND MEDICINE 

Stands out along the neck like cords. The general impression of 
the face is repulsive and corresponds closely to the face of rage 
as described by Darwin.^ The lips, however, are more retracted 
than during the purely emotional state and the clenched teeth are 
exposed, presenting the appearance of one in readiness for tearing 
o^ seizing the enemy. 




Fig. 2. — The expression of effort seen in throwing the hammer. 

In his drawing of rage Sir Charles BelP shows a face corre- 
sponding closely in many respects to this one of strain. 

The eyes are shut with force in all violent effort, such as shout- 
ing, sneezing, crying, or laughing, where the compression of the 
heart and lungs, by the muscular contraction of the chest-walls, 
drives up the blood-pressure to the point of seriously endangering 
the delicate vessels of the eye from overdistention, the hammer- 
thrower or the sprinter would shut them if he could. Indeed, the 
hammer-thrower often does close his eyes at the moment of greatest 
effort. The great skin muscle of the neck, the platysma, springs 

^ " Expression of the Emotions in Man and Animals." 
" " Expression of the Emotions.'' 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 21 

into action wherever violent effort is performed, as in delivering 
a blow, and sometimes even in testing the grip by the dynamo- 
meter. It is the muscle of emphasis. 

Games and feats of speed, in which many movements must be 
repeated as quickly as possible in a certain limited time, may well 
be classed as exercises of effort, since practically all the conditions 
of a single effort apply to them. 

In a loo-yard dash, occupying about ten seconds, the con- 
centration of attention is continued at its highest point throughout. 
The breath is held, and the whole muscular system is convulsed 
with supreme eft"ort, while the blood-pressure rises, much as 
it does in the single effort of throwing the hammer or putting the 
shot. If, however, the rate be reduced and the runner be allowed 
twenty seconds or more to cover the loo yards, the nervous 
tension disappears; the blood-pressure is but little affected; there 
is no nervous explosion, and the face remains calm and smiling. 

The same exercise becomes, under these conditions, one of 
mild endurance; and the possibility of this transition in the same 
exercise from effort to endurance, or from endurance to effort, 
must be constantly borne in mind, much confusion having occurred 
by the careless use of these terms. 

Feats of skill, such as juggling, are composed of isolated efforts 
which may be so mild in nature and so often repeated that they 
insensibly shade off into feats of endurance, especially when skill 
and practice render them automatic. The striking of a fortissimo 
chord on the piano is an exercise of effort. The practice of one 
scale for an hour would be an exercise of endurance, but the play- 
ing of the thirteenth rhapsody of Liszt, combines both effort and 
endurance. 

The qualities cultivated by exercises of effort, whether of 
strength, skill, or speed, include mental concentration; the rapid 
response of the muscle to the will power; the ability to learn com- 
plicated coordinations and the knowledge of the easiest and most 
economic way of performing difficult movements. Their prac- 
tice is followed by increase in the size of the muscles employed up 
to their physiologic limit. If carried past the limit of power, the 



22 EXERCISE IN EDUCATION AND MEDICINE 

muscles will refuse to contract, or may actually tear, and if habitu- 
ally overworked, they may atrophy, and become hard and fibrous, 
with weak, uncertain movements. When muscles are over- 
developed, they become parasites on the vitality, which is sapped 
in the struggle to provide for their nourishment. Exercises of 
effort do not cultivate constitutional vigor to the same extent as 
those of endurance. 

In exercises of endurance the range and variety of movement 
are usually much more limited. They are confined to a few 
well-known varieties, such as walking, running, and rowing, and 
though each movement is well within one's power, the total 
amount of muscular work is great, but as the contraction and 
relaxation is comparatively slow, the poisonous waste matter pro- 
ducing fatigue is removed from the muscles as it accumulates. In 
exercises of effort there is no time for the scavengers to work, 
fatigue of the most active muscles setting in rapidly, while in 
exercises of endurance they can, at least, postpone its. onset. 

This class is, then, milder and more general in character. 
It deals with coordinations familiar from infancy. It is not neces- 
sary to concentrate the attention on every movement in walking, 
running, and rowing, — typical exercises of endurance, — in them the 
mind may be occupied with other thoughts. Breathing, which is a 
muscular action of endurance, is entirely automatic, but is not 
subject to the ordinary laws of fatigue. 

The qualities cultivated by exercises of endurance are different 
from those required in effort. Skill is not prominent among them. 
Concentration is replaced by the attempt to liberate the attention, 
and the development of any one group of muscles is secondary to 
the indirect effect on the circulation and respiration in training 
them to remove the fatigue products of muscular contraction. ' 

When carried to excess, exercises of endurance are accompanied 
by acute constitutional exhaustion, shown in breathlessness, from 
which recovery is rapid; by fatigue of the whole muscular system, 
from which a rest of a day or two is necessary, and by the chronic 
or nerve fatigue known as "staleness" among trainers, from which 
recovery may be a matter of weeks or even months. 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 23 



Fatigue appears in one of these three ways. 

If the exercise be sufficiently active, the amount of waste 
material suddenly thrown into the circulation is greater than 
can be eliminated by the lungs. The breathing becomes rapid 
and shallow, the pulse 
quick and fluttering, and 
the runner feels a sense of 
constriction around the 
chest; his head swims and 
throbs and his face takes 
on the anxious expression 
so eloquently telling of the 
thirst for air. 

The face of the breath- 
less man is unmistakable. 
The smoothness of the fore- 
head is broken by wrinkles 
spreading out over the inner 
end of the updrawn eye- 
brows. The general direc- 
tion of the eyebrows is just 
the reverse of that seen in 
violent effort. They are 
drawn upward and inward 
by what the French call 
"the muscle of pain," 
whose action is seen in the 
expression of grief, mental 
distress, anxiety, or bodily 
pain. The upper lids in 

breathlessness droop and half cover the eyeball, giving a look of 
great lassitude to the suffering expressed by this region. The 
nostrils are widely dilated, and the mouth gapes, with lips retracted 
in the mad struggle for air. The raised upper lip adds to the look 
of sorrow and pain, while the down-drawn mouth angle, the tongue 
closely pressed against the teeth, the sunken check, and the open 




Fig. 3. — The typical face of breathlessness as 
seen in any race above 200 yards (modeled 
from life by the author). 



24 EXERCISE IN EDUCATION AND MEDICINE 

mouth, all go to increase the exhausted, haggard look so character- 
istic of this state, in distinction to mere bodily pain or mental 
suffering. The general poise of the head is backward, the chin 
thrust forward, and the neck strained or convulsed. 

With the reestablishment of equilibrium between the produc- 
tion of waste and its elimination, the urgency of breathlessness 
fades and the runner gets what is called his "second wind." The 
look of distress disappears from his face. The lungs regain fresh 
power to expand, the head becomes clear, and the muscles act with 
renewed vigor and elasticity. 

He can now continue running until he feels the symptoms of 
general fatigue. 

If the pace has been slow enough, the runner may escape the 
acute poisoning shown by breathlessness, but sooner or later the 




Fig. 4. — The typical expression of breathlessness is seen in the last nian. 

products of tissue waste accumulate, the heart beats fast and 
weak, the nervous system is stupefied, and the muscles relax. 
This may, in extreme cases, end in death from overexhaustion, as 
has been reported in soldiers after long and forced marches. 

The same condition may be studied in the face of the runner 
during a long distance race. After the urgency of breathlessness 
has passed, the expression of his face changes. The eyebrows 
show a slight frown, and the eyelids are heavy, as with sleep; the 
upper lip is still retracted from the teeth, giving a slight look of 
pain to the cheek, otherwise relaxed and flaccid. The mouth is 
half open, the jaw drops, and the lower lip hangs loosely over the 
parted teeth. The general expression is one of vacancy. As fatigue 
becomes more profound, his effort is centered in an endeavor 
to prevent the eyes from closing, as a consequence of the 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 



25 



increa'sing paralysis of the muscles of the upper eyelids. The 
long, doubly curved wrinkles across the forehead of this 
mask (^Fig. 7), which shows advanced fatigue, or the last 
stage of exhaustion, are usually associated with the expression 
of surprise and astonish- 
ment, but here they illus- 
trate the endeavor to raise 
the drooping eyelid. The 
nostrils are dilated, the lips 
are drawn downward and 
outward, the lower part 
of the face expressing the 
distress of failing respira- 
tion. The head is thrown 
backward and the chin 
thrust forward in the en- 
deavor to balance the head 
without muscular effort. 
Both pose and facial ex- 
pression are characteristic 
of the last effort to fight 
off collapse. When this 
last effort is exhausted, the 
mmscles of expression cease 
to act, the circulation fails, 
the color becomes pale, 
the lips livid, and the runner 
falls in a faint. 

The effect of this general fatigue does not usually pass away for 
a day or two. The body temperature rises several degrees, the 
patient is tired, perhaps delirious, and his night is sleepless or 
disturbed by troubled dreams. The urine passed is of high 
specific gra\'ity and contains albumin. The soreness and stiffness 
of the muscles and joints remain for several days, and gradually 
fade away as the constitution recovers its tone. 

This may be said to represent the second form of general 




Fig. 5. — The typical face of fatigue seen after 
acute breathlessness has passed off in a distance 
race (modeled from life by the author). 



26 EXERCISE IN EDUCATION AND MEDICINE 

fatigue — the subacute. The third or chronic form is found in 
men during a course of training in which the amount of endurance 
required daily is more than can be regained during the periods of 
rest. The exhaustion that finahy comes on is slower, but more 
profound in its effects and more difficult to counteract, than either 
the acute form, corrected by a few minutes' rest, or the subacute- 
form, which recovers in a couple of days. In this condition the 
temperature becomes subnormal, the weight goes down, the skin 
looks pale and flabby, the muscles lose their elasticity, the eye 
becomes dull and listless, interest in exercise ceases, every effort 
becomes a burden, and the patient sits without ambition or the 
power to rouse himself from his lethargy. 




Fig. 6. — Both faces show the typical expression of fatigue. 

Recovery from chronic fatigue, or overtraining, is a matter of 
weeks, and since the nervous system is profoundly affected, a 
change of air, surroundings, and occupation, with complete muscu- 
lar rest, may be necessary. 

It is a well-founded rule among trainers to give long distance 
runners a rest of two or three days before a race to recover com- 
pletely from the fatigue of the last practice run. 

Long distance running has been taken as the typical exercise of 
endurance, but just as we found that an exercise of effort might 
become one of endurance, so long distance running may vary 
sufficiently in its pace to make it an exercise in which effort plays 
a more important part than endurance. In a mile race the runner 
will carefully regulate his pace so that the waste matter of muscular 



THE DEFINITION AND CLASSIFICATION OF EXERCISES 



7 



contraction can be eliminated almost as quickly as it is produced, 
and his resources husbanded for the moment when experience 
teaches him he can exert all his latent power in the final spurt. 
This is so timed that the finish line will find him completely breath- 
less and exhausted. 

A mile race is, then, 
an exercise of endurance 
throughout most of the dis- 
tance, and at the finish an 
exercise of effort, the 
change showing by the ex- 
pression of the face. It is 
in finding out the pace and 
the point at which effort 
must begin that the genius 
of the true athlete is seen 
or the skill of the trainer is 
shown. 

Exercises of endurance, 
then, have much more pro- 
found influence on the gen- 
eral system than exercises 
of eft'ort. 

In the typical exercises 
of effort, such as feats of 
strength or skill, the result- 
ing fatigue is principally a 
local one, and includes 
soreness of the muscles 
most strongly in action, which refuse to function when the effort 
becomes too great. 

In exercises of endurance the constitutional fatigue is greater 
and powerfully affects the heart, lungs, general muscular and ner- 
vous systems. 

Passive exercise finds its widest field of usefulness in conditions 
of fatigue, where the elimination of waste matter must be assisted. 




Fig. 7. — The typical face of exhaustion seen 
just before collapse in a distance race (modeled 
from life by the author). 



28 



EXERCISE IN EDUCATION AND MEDICINE 



and where nutrition of the part is impaired or destroyed. The 
patient remains inert and is acted upon by the operator oi his 
mechanical substitute. Muscles can be improved in size, tone, 
and nutrition, ligaments stretched and strengthened, the general 
circulation quickened, and overloaded veins made to disgorge 




Fig. 8. — The finish of a race, showing effort on the right, exhaustion in the center, and 

collapse on the left. 



their blood. The digestive tract can be stimulated to more 
active habits, and overwrought nerves soothed and relieved of 
their hypersensibility. 

The full and detailed description of the typical movements of 
massage will, however, require a chapter to itself. 



CHAPTER II 
THE PHYSIOLOGY OF EXERCISE 

Bodily movements affect profoundly the motor apparatus, 
the vessels which supply it with nourishment in the form of blood 
and lymph, the storehouses of nutrition in the abdomen, and the 
controlling and directing mechanism of brain and nerve. 

The impulse to contract a muscle begins at its motor center 
in the brain or spinal cord^ and is carried to it by a motor nerve. 
Each muscle-cell shortens and thickens, scattering some of its sub- 
stance into the lymph-space encircling it, and absorbing food con- 
sisting of carbohydrates and oxygen from this surrounding plasma. 

By repeated contraction the cells increase in size and number, 
the perimysium is strengthened, the fibrous wall surrounding the 
bundle of cells is invigorated, and fresh power is imparted to the 
sheath inclosing the entire muscle. The result is an increase in 
bulk, in strength, and in elasticity. The tone of a healthy muscle 
keeps it in slight contraction even when at rest, so that antago- 
nistic groups retain the inactive limb in normal position, but con- 
stant overaction and strengthening of one group of muscles increases 
this normal tension until the accustomed pose becomes habitual, as 
in the curved fingers or bent arms of the oarsman or weight- 
lifter. 

During contraction there may be actual rupture of the cell- 
walls and exudation of blood and lymph. This is one of the two 
causes of muscle soreness found after severe straining exercise. 
The other cause is the presence of irritating waste matter imper- 
fectly carried off by the blood-stream. This process of elimination 
is improved if the muscle be kept warm, but as muscular action 
generates heat, this usually regulates itself. When the liml) is cold 
or inactive, the heat of the muscles must be enkindled by prelimi- 
nary massage and light exercise l^efore undertaking with safety any 

29 



30 EXERCISE IN EDUCATION AND MEDICINE 

severe athletic test. The lack of this precaution in cold weather 
is the cause of most ruptured muscles and tendon strains. Galen 
recognized this fact in the second century and writes: "If any one 
immediately after undressing proceed to the more violent move- 
ments before he has softened the whole body and thinned the 
excretions and opened the pores, he incurs the danger of breaking 
or spraining some of the solid parts, . . . but if beforehand you 
gradually warm and soften the solids and thin the fluids, and 
expand the pores, the person exercising will run no danger of 
breaking any part." 

The overproduction of heat is fairly well equalized by evap- 
oration through the skin and lungs, although general massage is 
followed by a slight rise in temperature, and there is always 
some fever attending and following a long distance race. 

The effects of the three kinds of exercise described in the 
previous chapter on the structure and behavior of the muscle vary 
widely. Single and complete contraction, however mild the 
resistance, improves the nutrition if frequently repeated, as shown 
by an increase in size and efficiency. When, however, the tension 
is habitually excessive, minute ruptures occur in its substance and 
sheath, fibrous deposits are formed, and the muscle itself becomes 
shortened, hard, and inelastic. Even when at rest, the specialist on 
the horizontal bar wall show the rounded shoulders, the bent arms, 
and curved fingers developed by too exclusive devotion to this 
exercise. 

The number of muscles involved in a simple movement multi- 
plies with the intensity of the effort. The trial of grasping power 
by the hand dynamometer is designed to test the flexors of the 
hand and forearm, but in the strife for additional force, muscular 
contraction spreads to the arm and shoulder and throughout the 
entire muscular system until its intensity is expressed by the face. 
If, however, skill is an important factor in the exercise, the em- 
phasis on alacrity and accurate control cultivates in the muscle 
economy of effort and promptness in responding to the will. 
In other words, the latent period is shortened. 

In exercises of endurance each movement is comparatively 



THE PHYSIOLOGY OF EXERCISE 3 1 

mild, and there is less tendency to shortening and stiffening of 
the muscle so frequently found after extreme effort. Develop- 
ment is general rather than local, and long distance runners are 
not noted for the thickness of their calves. 

General nutrition is best improved by the rhythmic self-massage 
of movement. " Every muscle is a throbbing heart, squeezing its 
vessels empty while in motion and relaxing to allow them to fill up 
anew" (Weir Mitchell). The element of skill does not play an 
important part in such habitual or &,utomatic movements as walk- 
ing or running, so that their value in its promotion is compara- 
tively slight. 

Passive exercise improves the nourishment of the muscle-cell 
by forcing out the products of fatigue and keeping it bathed in a 
constantly renewed stream of arterial blood. This alone is suffi- 
cient to prevent wasting of substance in conditions where active 
movements are impossible, but it has little power to modify 
m.uscular strength or control. 

It can be demonstrated that the amount of blood in the 
muscle, as in the heart, varies with its contraction and relaxation. 

Mosso, of Turin, found that an arm inclosed in a water plethys- 
mograph (Fig. 9) diminished in volume on contracting the flexors 
and immediately increased above its original volume when they were 
relaxed. He also found an increase in the amplitude of the pulsations 
of the whole arm during and after the contraction of the flexors. 
These experiments have been confirmed by Sir Lauder Brunton 
and other observers, and it may be considered as conclusively 
proved that the blood-vessels are substantially enlarged in the 
active muscle after contraction, and during the contraction itself 
the interchange of products between blood and muscle is also 
accelerated. Xot only is this true, but the actual nourishing power 
of the blood is augmented by this heightened activity. 

It has been proved by Hawk, in his interesting experiments on 
the Ijlood-count of athletes in training' at the University of Penn- 
sylvania, that various forms of active muscular exercise produce 
an average increase of 16.8 per cent, in the num1)cr of red corpiis- 

^ " Am. Journal of Physiology," \'ol. x., Xo. viii. 



32 



EXERCISE IN EDUCATION AND MEDICINE 



cles, the greatest increase being 26.7 per cent, in a subject who had 
played water polo for a period of three minutes, the lowest increase 
being noticed after long runs and bicycling. When exercise is 
long continued, the rate of increase lessens and the number may 
even decrease in violent exercise sufficiently prolonged. This, 
he explains, is due to the passage into the circulating blood of a 
large number of cells lying inactive in various parts of the body 
until they are brought into service by the muscular exercise. 




Fig. 9. — A schematic diagram of Mosso's pleth^/smograph for the arms : a. The glass 
cylinder for the arm, with rubber sleeve and two tubulatures for filling with warm water; 
s, the spiral spring swinging the test-tube, .'. The spring is so calibrated that the level of 
the liquid in the test-tube above the arm remains unchanged as the tube is filled and 
emptied. The movements of the tube are recorded on a drum by the writing point, p. 
(Howell). 

John K. Mitchell gives the same explanation^ for a similar, 
increase found after massage. This would also account for the 
fact that they decrease after prolonged exercise in which this 
reserve, as well as the original circulating proportion, is. con- 
sumed in the furnace of muscular action. The specific gravity 
of the blood is heightened by evaporation from the lungs and this 
tends to mask the continual destruction of red cells in long tests of 

^ " Am. Journal of Medical Sciences," 1894, evil. 



THE PHYSIOLOGY OF EXERCISE 7,^ 

endurance, and in every course of athletic training the blood is 
still further thickened by restricting the amount of fluid ingested 
to replace evaporation. In this way the oxygen carriers in 
the blood are relatively increased, as are the white cells that 
destroy tissue waste. 

When exercise is sufficiently active, a larger blood-supply is 
required and its purification must be thorough. The rate of 
the heart-beat and of the breathing is accelerated, the heart driving 
the blood into the arteries with a more powerful stroke. The 
poisonous refuse of tissue waste eliminated by the lungs consists 
principally of CO2, about 4 per cent, of which replaces an almost 
equal amount of oxygen absorbed at each breath. The respiratory 
center is also stimulated to increased activity by the circulation of 
lactic acid and acid phosphates in the blood as a result of muscular 
contraction. 

An additional amount of CO2 can be eliminated by using a 
larger surface of the lung tissue than is employed in ordinary life, 
without any great increase in the rate of breathing. Increased 
power of elimination can thus be acquired by practising move- 
ments of artificial or forced respiration which strengthen the acces- 
sory breathing muscles of the chest and stretch the thoracic cavity. 
It is, however, only with greater respiratory need that the absorp- 
tion of oxygen takes place. To produce all the conditions neces- 
sary for an increase of respiratory power, active exercises causing 
actual tissue waste are thus required. 

The onset of respiratory fatigue can be postponed by "condi- 
tioning^' or decreasing the watery constituents of the blood through 
limiting the drmk, as already referred to, and feeding with rich 
albuminous foods, both of which will increase the oxygen-carrying 
ability of the blood. To this is added muscular training, through 
exercises of endurance, to improve the quality of the tissues. 

If the amount of muscular work be increased beyond the rate 
of elimination, acute general fatigue or breathlessness is inevitable, 
even in the man who has been put in the best condition. It is 
characterized by rapid, shallow breathing, a sort of resi)iratory 
madness, a fluttering pulse, and such symptoms as singing in the 
3 



34 



EXERCISE IN EDUCATION AND MEDICINE 



ears, dizziness, and a feeling of suffocation, while accompanying 
the thirst for air is mental anxiety, confusion, and even uncon- 
sciousness. The facial expression of the breathless man has been 
already described. 

This physical distress is preceded by a period of stimulation 
in which the eye becomes bright, the skin flushed, and a warm 
glow is felt from the dilatation of the capillaries. This dilatation 
of the capillaries is a sign of the increased power of the heart-beat. 




Fig. lo. — Stanton's sphygmomanometer: i, Leather cuff in place on the arm; 2, 
bulb grasped in hand for pumping air into the tube under the cuff to obliterate the 
pulse ; 3, glass tube graduated to show the height of the column of mercury required 
(Da Costa). 

which exalts the tension throughout the whole arterial system and 
drives the blood with quickened stream through vessels which at 
rest are almost empty. 

Blood-pressure is also raised by any obstruction of its return 
to the right side of the heart. The causes of raising or lowering 
it will be considered more fully in an analysis of the influence of 
exercises of effort and endurance on the circulation. 

The measurement, then, of arterial tension is exceedingly 
important. This is done by a sphygmomanometer, such as Stan- 



THE PHYSIOLOGY OF EXERCISE 3^ 

ton's modification of the Riva-Rocci instrument. The brachial 
artery is compressed by strapping around the arm a leather collar 
four inches in width, beneath which is a rubber tube, the air being 
pumped into it until the radial pulse is obliterated. The amount 
of pressure required to do this is measured by the height of a 
column of mercury forced into a graduated upright glass tube 
(Fig. lo). 

The normal systolic pressure, according to Janeway, who him- 
self invented an instrument, is 145 milometers. Anything under 
160 he does not consider abnormal. 

Sir Lauder Brunton's observations give 120 as normal for 
young adults, and from 115 to 140 for men in middle life. He 
considers anything above 150 as abnormal, although he notes hav- 
ing found men apparently in good health with a pressure of 180. 
He considers them, however, to be in a precarious condition. 

A series of 500 observations taken with the Stanton machine, 
by Dr. A. E. Newton and myself on college students lying 
supine, shows an average of 135, which is lower than Jane- 
way's and about the same as Sir Lauder Brunton's of normal 
young adults. 

The observations of O. Z. Stephens/ in various positions, 
showed the following mean pressures: Standing, 13 1.6; sitting, 
134; supine, 150.4; head down, 165.6; right lateral, 134.5; left 
lateral, 133. 

In exercises of effort or speed, such as lifting a heavy weight, 
wrestling, throwing the hammer, or sprinting, the muscles of the 
chest-wall that assist in supporting the arm and shoulder come 
into energetic contraction, pressing on the elastic cushion of the 
lungs, so as to give the arm muscles a firm base of action. The 
teeth are clenched and the larynx is closed, corking up the air in the 
lungs, where it is still further compressed by the contraction of 
the abdominal muscles. \^iolent pressure on the thoracic contents is 
thus produced, and the \'entriclcs of the heart empty more (piickly 
and completely than is their habit. This is especially true of the 
left ventricle and the aorta. The coronary arteries, which give nour- 

' "Journal Am. Mefl. .Assoc," Oct. i, 1904. 



36 



EXERCISE IN EDUCATION AND MEDICINE 



ishment to the heart, are compressed, and the circulation of the 
heart-muscle partially arrested, while the refilling of the thin- 
walled auricles is hindered. The blood in the arterial system is 
dammed back by the resistance in the engorged veins, and the 
superficial veins of the neck, temples, and forehead swell up like 
cords (see Fig. i), and the complexion becomes first red and then 
dusky. 

The blood-pressure mounted to over 200 mm. in a series of 
experiments by McCurdy^ in a back and leg lift in which the effort 
was maximum, but the blood-pressure fell at once when the ob- 



The blood 


pressure 


in eleven 


men before, during, and after lifting with maximum strength ; the pulae rate 
of several observations made on each individual. 


* before and after the lift Average 


Name, 


Age. 


Weight 
Itilos. 


Weight 
lifted in 
Mos. 


Before lift. 


During 
lift. 


2-3 minutes after 
• lift. 


No. of beats in dis- 
tal artery between 
compression and 
disappearance of 
pulse. 


Condition of arm. 


Pulse 


Blood- 
pressure, 
mm. Hg. 


Blood- 
pressure. 


Pulse 


Blood- 
pressure. 


Sk. 


31 


70 


216 


69 


109 


210 


74 


113 


1-4 




Moderate size, muscular. 


Ma. 


23 


61 


118 


93 


109 


165 


94 


107 


14 




Small, not muscular. 


De. 


30 


60 


131 


75 


93 


14<5 


76 


95 


I 




Small, not muscular. 


Sa. 


31 


68 


1S3 


67 


100 


17S 


67 


101 


1-2 




Large, muscular. 


McC. 


33 


75 


170 


73 


124 


173 


81 


125 


1-2 




Moderate size, niuscular. 


Ar. 


21 


75 


17S 


77 


117 


207 


SO 


117 


1-3 




Large, muscular. 


St. 


41 


83 


149 


78 


122 


202 


77 


114 


1-3 




Large, muscular. 


HL 


25 


60 


155 


84 


100 


154 


80 


107 


1-2 




Small, not muscular. 


Be. 


26 


61 


133 


77 


103 


157 


78 


108 


1 




Moderate size, muscular. 


Me. 


27 


72 


249 


76 


107 


188 


78 


110 


M 




Large, muscular. 


Ja. 


26 


75 


152 


73 


127 


197 


74 


130 


1-2 




Moderate size, muscular. 



^ The pulse rate was recorded in the recumbent as well as the standing position. It seemed necessary tp give here only the figures fof 
Ihe standing position. The glottis was closed during each lift. 

Fig. II. — Summary of experiments made by J. H. McCurdy. 



struction to the return flow was removed, equilibrium in the circu- 
lation being rapidly established, and little acceleration of the pulse- 
rate being noted (see Fig. 11), the disturbance above described 
varing directly with the severity and length of the effort. We find 
then the greatest strain on the heart and blood-vessels in exercises 
of strength and speed, more especially in all feats where the arms 
are used to lift or pull great weights, or to support the body, these 
movements involving as they do fixation of the chest-walls. 

From the above it will be clear that exercises requiring sudden. 

1 "Am. Journal of Physiology," Mar. i, 1901. 



THE PHYSIOLOGY OF EXERCISE 



37 



and great muscular effort should be used with caution in those 
whose arteries have lost the first resiliency of youth, for in them 
damage may easily occur, although in youth no voluntary effort 
can be violent enough to burst a healthy vessel. Such exercises 
are a test of their quality rather than a means of systematically 
developing them, and no system of physical education composed 
exclusively of such exercises can lay just claim to completeness. 
It is to exercises of endurance that we must look for the sys- 
tematic development of strength and resistance in the heart and 
arteries. In mild, rhythmic movements the blood-pressure and 



Temp. Pulie 




















































































140 












,,y 




-»,^ 
















































..... 
















IJO 
99 

100 
























_^. 


X 


-.«_^ 














/I.'" 


1 


— 


— 


— 
















"* 


'-». 











/' 
































* 


— 


— 


/ 
























\ 










































\ 


\ 












































"^ 


^ 


, 


-.^ 


, 




It 






















1 


• 















3:p.M. 9:15 3:30 «:46 4:00 4:15 4:30 

Fig. 12. — Changes in pulse-rate and temperature of the body during a bicycle ride 
of one hour and during rest for the half-hour following. The solid line (P) indicates 
the pulse-rate, and the broken line {T), the temperature. Arrows indicate the beginning 
and end of the work (Wilbur P. Bowen). 



temperature rise gradually and never attain a great height. They 
remain high after the exercise is finished, and then drop to sub- 
normal much more slowly than the pulse-rate. The pulse-rate 
rises abruptly, remains high, and drops suddenly at the end 
of the exercise. During this period the circulation is carried 
on with increased force and rapidity, but without great overstrain 
(Fig. 12). 

In Bowen's experiments on bicycle riding he found that speed 
had a much more potent influence than resistance in raising this 
rate. 



38 EXERCISE IN EDUCATION AND MEDICINE 

Owing to the profound influence of exercise on constitutional 
vigor, it should be regulated with great care in relation to the age 
of the patient. According to Benke's statement, the volume of 
the heart in children is to the diameter of the arteries as 25 to 20, 
in adolescence it is 140 to 50, after full maturity, 290 to 61. During 
this period the volume of the heart is increased twelvefold, while 
the diameter of the arteries is increased only threefold. 

If the length of the body be considered as 100, the heart 
volume would be from 40 to 50 in the child, while the heart of 
a- mature person would be 190. The child's growth then would 
be in relation to and dependent upon this developm_ent of the 
heart, and upon the possibility of increased pressure of the blood 
in the arteries caused by their proportionate narrowing. 

"Athletic training is mainly heart training."^ Exercises of 
endurance distribute the activity widely, and gradually approach 
the maximum without interfering mechanically with the respi- 
ratory movements. They do not require supreme efforts, but 
they accelerate the activity of the heart and lungs, at least so 
long as the exercise lasts. The aggregate of work done is very 
much greater than in exercises of strength. Such exercises must, 
however, be active enough to provide for the free circulation of 
the lymph, which is carried on mainly by the massage of muscular 
contraction. If a walk be listless enough, there may not be suffi- 
cient movement of the muscles to thwart the pernicious influence 
of gravity acting on the column of blood contained in the veins 
of the belly, thighs, and legs, and the vessel walls may still become 
permanently stretched and varicose. 

Massage mechanically excites the vessels to action, empties 
the lymph-spaces, and hastens the circulation. It usually raises 
the general body temperature- as well as the part manipulated, and 
through these means it removes fatigue products, increasing the 
muscle irritability lost from overwork or disease. 

Many mo\'ements may be chosen because of the automatic 
massage given to the larger vessels by the action of the limbs as 

^ Roy and Adami, " British Medical and Surgical Journal," 1888, No. 1459. 
^Weir Mitchell, " Fat and Blood." 



THE PHYSIOLOGY OF EXERCISE 39 

well as the muscles. Eversion and extension of the thigh stretches 
the deep fascia and presses on the crural vein underlying it. If the 
thigh be turned inward and flexed, the fascia relaxes, drawing the 
vein wall connected with it upward, and thus mechanically 
enlarging it. If the thigh be now completely flexed and inverted, 
pressure is again exerted on the vein. The rhythmic repetition of 
these motions of the thigh pumps the blood toward the heart, the 
valves of the veins allowing it to flow in that direction only. This 
process is continually at work in such movements as climbing, 
rowing, sliding, skating, and swimming. 

The muscles are the slaves of the nerve-centers, and in fatigue 
the will tires long before the contracting power of the muscle is 
lost, for if the motor nerve to the fatigued muscle be cut, feeble con- 
tractions can be strengthened by artificial impulses of electricity. 

Fundamental movements, such as breathing, eating, speaking, 
and walking, become, through constant repetition, automatic early 
in development, and the management of them is turned over to 
lower centers in the hind brain and cord, so that the motor area of 
the highly developed cortex may be devoted to those accessory 
coordinations that are never automatic and need long training to 
become habitual — such as piano-playing or juggling. 

The acquirement of skill is, then, a training of the nerve rather 
than of muscle, if it is permissible to speak of them separately in 
this connection. 

The simplest movement means not only a nerve impulse to the 
acting muscle, but a wave of impulses to the accessory and antago- 
nistic groups which must control and steady the movement. If the 
movement is unfamiliar, this contraction will be jerky and inaccur- 
ate instead of unerring and graceful, or, in other words, physiolog- 
ically economical. Many useless muscles will be employed, and the 
expense in nervous energy will be out of proportion to the resuh. 
The first attempt at comparatively simple actions rapidly exhausts 
the attention. The apparently aimless and uncertain movements 
of a child learning to walk illustrate the amount of concentration 
at first required in what afterward becomes automatic. 

Exercises of skill cultivate habits of economy in the expenditure 



40 EXERCISE IN EDUCATION AND MEDICINE 

of nerve force, and we instinctively admire a difficult exercise 
performed with thrifty ease just as we unconsciously censure the 
nervous prodigality of the unskilful tyro. The distracting influ- 
ence of mental excitement or worry is seen in the broken shoe-lace 
of the hurried man and the failure of the nervous pianist before a 
critical audience. 

When a certain degree of skill or coordination is learned, the 
interest passes on to what is more difficult, and this is one reason 
why any course in physical training should begin with simple and 
easily learned coordinations, progressing to those more difficult 
and complicated feats that serve to keep alive the attention and 
interest of the pupils. 

Exercise should also be designed to develop and educate 
movements that are peculiar to the limb, the lower limb for support, 
locomotion, and leaping; the upper limb for grasping, striking, 
throwing, and catching. It is because this great principle is so 
much neglected that the interest is difficult to maintain in 
formal gymnastics. In free play this takes care of itself. 

Exercises of strength and skill train that alertness of mind so 
necessary in ordinary life. They shorten the period between 
thought and action, and give that condition known as "presence 
of mind." This cannot be done without a corresponding mental 
strain. The man who is held alert too long on the starting line 
before a race, tense and straining for the signal, finds such a rapid 
exhaustion of his powers of concentration that in a second or two 
the strain becomes intolerable. The alertness required at first 
in learning to box, rapidly exhausts the nervous system, and it 
is only when the movements of countering, ducking, and side- 
stepping become habitual that the exercise can be continued for 
any length of time. Football is a game of the same nature, and 
"getting the jump" on an opponent is a matter of mental concen- 
tration and alertness rather than of actual strength. Much of the 
exhaustion of a game is due to this brain-fag, for the actual play- 
ing time in an hour's game is only four or five minutes at the most. 

In gymnastic exercises imitation is a cheap form of instruction 
from the standpoint of nervous expenditure, because the pupil 



THE PHYSIOLOGY OF EXERCISE 4I 

learns more easily through the eye than by translating a \'erbal 
command into a picture of the movement, while exercises by com- 
mand are much more exhausting to the attention of the pupil, but 
they have thus an additional educational value. This is the ques- 
tion upon which most of the wars between rival systems of gym- 
nastics have been fought. 

Exercises of endurance, which are simple, habitual, or even 
automatic, do not require great nervous concentration. A man 
can walk or run and have his mind on other things, but 
when they are carried to the point of acute fatigue, the 
phenomena of breathlessness, already described, takes place. If 
the exercise be continued after breathlessness has disappeared, the 
runner soon begins to notice a sensation of lassitude creeping over 
him, shown by an increasing lethargy and paralysis of the will 
power. His muscles become slower and slower in their response 
to his will; each effort requires a greater concentration of his 
attention. This lassitude gradually deepens; group after group 
of muscles refuse to perform their work, until he staggers along 
with relaxed grip, yielding ankle, fallen jaw, and drooping eye- 
lids — drunk with the poisons of fatigue. 

Repeated attacks of fatigue produce that chronic poisoning 
referred to in the last chapter as staleness or overtraining, which 
is, above all, a slow poisoning of the nervous system, just as sub- 
acute fatigue was a general intoxication by the products of mus- 
cle waste, and acute fatigue — an intoxication of the breathing 
apparatus. 

The role of passive exercise is one of relief to the nervous 
system, for the nutrition of muscles may be maintained without the 
expense of nervous force required to make them contract, and mas- 
sage acts on the central system through the nerves of sense, stimu- 
lating or soothing, according to the nature and amount of the 
manipulation. 

The absorption of carbohydrates and proteins by muscular 
action causes a hunger for food, just as the using of oxygen ])ro- 
duces a hunger for air. With the supply of food the muscles in- 
crease in size anrl strength, and the amount remaining unused is 



42 EXERCISE IN EDUCATION AND MEDICINE 

excreted or stored up in the tissues as fat. If training be 
severe, this natural horde of fat is speedily expended, and a man 
in fine athletic condition is always below his normal in fatty 
tissue. Athletic training aims to produce a machine to run, 
leap, fight, or row, and fat would only be an encumbrance, so 
that a man in fine athletic form would not be in the best con- 
dition to resist the siege of an exhausting infection, like typhoid 
fever or pneumonia, where the stored-up fat of the normal 
individual becomes his most valuable asset. The loss of weight 
during athletic exercise may be from five to eight pounds in less 
than half an hour, a loss which is continued after exercise is stopped 
if no food or drink is taken. In a series of observations made on 
foot-ball players during practice at the University of Pennsylvania 
I found that the loss averaged about three pounds, the highest 
being 5.1 pounds and the lowest .8 pounds, the weights being 
taken immediately before and after exercise. The men were 
then wrapped in blankets or allowed to sit around for an hour, and 
showed a further loss of one-half pound, the greatest loss being .9 
pounds and the smallest nothing. In no case was any gain found. ^ 

It has already been shown that the first two organs to act in 
the elimination of the poisons of muscular waste are the lungs and 
the skin, the former giving off heat, CO2, and water vapor, and 
the latter, water, urea, and other constituents of minor importance, 
in addition to neutralizing the heat produced by muscular action 
through evaporation. This loss of weight from the skin and 
lungs goes on even during sleep, as shown by the delicate bal- 
ance used by Warren P. Lombard in his experiments^ (Fig. 13), 

From 107 observations on healthy men averaging 64.5 kilos 
in weight he concludes that the loss of weight is 0.692 gm. a 
minute, of which .525 is from the air passages and .166 or 
about 24 per cent, is from the skin. The ehmination by the 
skin alone was obtained by holding the breath in expiration. 

1 For the carrying out of these experiments I am indebted to my assistant, W. 
J. Cromie. 

-Reported at the Siebenter Internationaler Physiologen-Congress, Heidelburg, 
1907. 



THE PHYSIOLOGY OF EXERCISE 



43 



The effect of CO2 has been graphically shown by Lee in his 
work on the action of fatigue products on muscular contraction. 



a. 




l^ 




7.7= 


'■'^^***sN. 






/ 


s 


. E66= O.JTBm^ 




I 


r% 




Fig. 13. — Curve of loss of weight of F. M. A. (aged 29, weight 72 kilos), 5.30 
p. M., May 24, 1906. Room temperature, 24.5° C; hygrometer, 55 degrees. The 
small oscillations were caused by the respirations. Time is marked in minutes at the 
bottom of the curve: a-b, subject asleep; b-c, waking curve; at c, 4 grams added; d-e, 
waking curve; at e, breath held in quiet expiration; at/, a large inspiration when sub- 
ject begins to breathe;/-^, curve shows rapid loss of weight following the holding of 
the breath. At b, he was partly asleep, eyes closed, lids twitching. He was told to 
open his eyes and did so. He was not startled and was not seen to make any other 
movement (Warren P. Lombard). 

In Fig. 14 the preliminary stimulation of the poison, already 
referred to, is seen in the higher curve of contraction found in 
the poisoned muscle at the lower part of the diagram. This 




Fig. 14. — Record of fatigue of companion gastrocnemius muscles of the frog, one 
normal, the other under the influence of carbon dioxid. The longer, or, in the later 
contractions, the lower curves, are those of the poisoned muscle. Every fiftieth contrac- 
tion is recorded (Frederic S. Lee). 

stimulation soon gi\-cs place to the slow and lowered line of llic 
upper part of the diagram. 



44 EXERCISE IN EDUCATION AND MEDICINE 

It still remains to speak of the function of the kidneys. Before 
and after the Marathon race, of twenty-four miles, at St. Louis, 
T904, the temperature of twelve contestants was taken (per rectum) ,^ 
showing a rise of from 2 to 3I degrees. This rise, also noted by 
Bowen (Fig. 12), is, I believe, constant, although it may not show 
if the mouth temperature be taken. The fever is accompanied by 
nephritis lasting several days, seen in the presence of albuminous 
urine containing casts. The other products of muscular action 
removed by the kidneys are water, uric acid, urea, oxalates, 
lithates, and numerous other substances. These show as reddish 
deposits (principally uric acid) in the urine, especially of those not 
habituated to fatigue, but quickly disappear with improved condi- 
tion. 

In the understanding of the place occupied by conditioning 
and elimination we have not advanced much, even in phrase- 
ology, on Hippocrates, who wrote that "The untrained have 
moist flesh, and when they exert themselves, the body becomes 
heated and they yield the product of liquefaction in abundance. 
Of this, whatever is sweated or purged away with the breath, causes 
no trouble except to so much of the body as has undergone the 
unusual depletion; but whatever remains causes trouble, not only 
to the unduly depleted part of the body, but also to whatever part 
receives the liquid in question, which is not akin to the body, but 
hostile." 

1 Notes taken by Dr. Luther Halsey Gulick, Joseph E. Raycroft, R. Tait 
McKenzie. 



CHAPTER III 
MASSAGE AND PASSIVE MOTIONS 

The word massage (Greek, niassein, to knead) is applied to the 
systematic manipulation of the body surface by the hands in move- 
ments of stroking, pinching, kneading, and striking. Passive 
motion consists in the flexion, extension, and other movements of 
joints and limbs by an operator or machine, without the co- 
operation or resistance of the patient. Both have been widely 
used since the beginning of history. Travelers have brought 
accounts of their employment in Turkey, Africa, Siberia, Lapland, 
Japan, China, and the islands of the Pacific. The lonii lonii 
of the Sandwich Islanders is spoken of with enthusiasm for 
its power of relieving the stiffness and soreness of fatigue, and 
procuring rest and sleep. The process is described as varied 
among kneading, squeezing, and rubbing, now one and now the 
other, each region being manipulated in turn, beginning with the 
head and working down slowly over the whole body, until in half 
an hour the weariness has quite disappeared, giving place to a 
most refreshing sense of ease and comfort. 

The history of massage has been checkered. The priests of 
Egypt used friction and kneading for rheumatic pains and neural- 
gia, and the priestly caste of India have always known and practised 
it. The Greeks had a class of "padotribes," or physicians, who 
acquired great skill in the manipulation of the body, just as at the 
present time the call of the blind masseur is a familiar sound in 
the streets of Tokyo. The Romans followed the Greeks, from 
whom so many of their customs were borrowed, but with them it 
often became a means of escaping the more rigorous forms of 
exercise and of removing the effects of overeating and drinking, 
the forenoon of the luxurious patrician being devoted to the batii 
and ejeneral massat^c. It has had its eras of i)0!)ularitv and its 



46 EXERCISE IN EDUCATION AND MEDICINE 

seasons of neglect, popularity usually due to the personality and 
skill of an operator, or school of operators, and neglect following 
its indiscriminate use by unskilled persons. In the middle of the 
last century Beveridges' rubbers were well known in Edinburgh, 
and their success carried it from that medical center throughout 
Europe. It then declined, but has been revived on a more solid 
and scientific basis by Fox, Norstrom, Graham, and especially 
by Mezger, of Amsterdam, whose classification is the one hab- 
itually followed to the present day. It is universally employed 
by athletic trainers to aid the elasticity and power of an 
athlete's muscles before a contest and to remove the fatigue fol- 
lowing exertion. 

In medicine a great impetus was given to its employment by 
Ling and his disciples in Sweden, and it now forms part of the 
Swedish system of remedial gymnastics. 

Its recognition as a therapeutic agent has been delayed by 
the failure to distinguish between true massage and unskilled 
rubbing, which merely requires muscular strength, a certain 
manual dexterity, and good will. To be a successful masseur one 
must possess these qualities before beginning the training necessary 
to learn its possibilities, but its practice should be preceded by an 
intimate and special knowledge of anatomy, the disposition and 
thickness of muscle groups, their septa, the point where muscle 
changes to tendon, the situation and course of the veins and 
arteries, and their anastomoses, the location of the nerve-supply, 
the movements of a limb, and the changes about the joint caused 
by movement, the situation and extent of synovial cavities and 
tendon-sheaths. This knowledge should be practical and con- 
tinually confirmed or corrected when the parts are at rest and at 
work. In addition to this there must be that touch, firm, insistent, 
yet gentle, that adapts itself to the hills and hollows of the body 
surface as if by instinct, and a buoyant constitutional vigor to 
withstand the exhausting character of its practice. It is for the 
reasons above enumerated that the practice of true massage is 
limited to the few that are willing and able to devote the time and 
study necessary for the thorough acquirement of its technic. 



MASSAGE AND PASSIVE MOTIONS 47 

The action of massage upon muscles in repose has been thor- 
oughly studied by Mosso and JMaggiora, of Turin, who chose for 
their experiments the fatigue curves of the right and left middle 
fingers in maximum voluntary flexion every two seconds with a 
weight of three kilos.^ These records were taken at eight and 
eleven in the morning and at two and five in the afternoon, with- 
out massage, and the following day under the same conditions after 
a friction and kneading of three minutes. The average of the re- 
sults proved that the muscles did twice as much work after the 




Fig. 15. — Normal voluntary curve of fatigue of the flexor muscles of the middle finger 

of the left hand, with a weight of 3 kilos and rhythm of two seconds. 
Fig. 16. — Curve of the same muscles with the same weight and rhythm, after massage 
for three minutes (after Maggiora). 

massage (Figs. i6 and i8). Maggiora also discovered that exten- 
sion of the period of massage did not produce any greater results 
in the capacity for work, fi\-e minutes obtaining all the needful 
effect. His experiments on the comparative value of the various 
manipulations proved that little difference existed in the effect of 
friction and percussion. There was a greater increase of work- 
ing capacity after the use of petrissage than from, cither of the 
other movements, but the best results were obtained by alter- 
nating all three. The effect of massage upon the muscles 

1 (iraham, " Recent Devclopnunts in Massage," 



48 EXERCISE IN EDUCATION AND MEDICINE 

weakened by fasting was such as to restore them temporarily to 
their normal condition. It also restored a normal fatigue curve 
that was reduced and shortened by a wakeful night (Figs. 19 
and 20). After an intense, prolonged intellectual strain of five 
hours in the final examination of medical students, Maggiora's 
fatigue curve was one-fifth of the normal. An hour later, 
after ten minutes of massage, the fatigue curve was almost 
completely restored. Perhaps the most interesting results 




Fig. 17. Fig. 18. 

Fig. 17. — Fatigue curve of flexors of right middle finger after a walk of ten miles. 

Fig. 18. — Shows the influence of massage for ten minutes upon the same muscles 
already indirectly weakened by walking. Weight, 3 kilos ; rhythm, two seconds (Mag- 
giora). 

obtained were in his studies of artificial- anemia of the muscles. 
After compressing the brachial artery, the finger could contract 
only II times in comparison to 265 times under normal condi- 
tions. While the arterial current was still shut off, three minutes 
of vigorous massage was given, after which the finger could con- 
tract only nine times, proving that massage had no effect when 
the blood-supply was intercepted. From these experiments it is 
evident that massage essentially affects the local circulation by 
bringing a greater quantity of nutrition to the muscles, and re- 



MASSAGE AND PASSIVE MOTIONS 



49 



moving the poisonous products loosened by their action. Its 
action in improving muscle tone, in postponing the onset of 
fatigue, and hastening recovery from it, has long been recog- 
nized by athletic trainers. In preparing athletes for a con- 
test, general massage is always given by friction, kneading, pinch- 
ing, and stroking, lubricating the surface with some oily liniment. 
After a hard race or other contest, it is a matter of common 
knowledge among trainers that a five-minute treatment will 




Fig. 19. Fig. 20. 

Fig. ig. — Fatigue curve of fle.xor muscles of middle finger of right hand after being 

awake one night. 
Fig. 20. — Shows the effect of ten minutes' massage upon the same muscles (Maggiora). 

enable an athlete to repeat or continue a performance otherwise 
impossible. 

Massage differs radically from active exercise in its capacity 
to feed muscular tissue without fatiguing or even employing the 
will power of the patient. It is the most economic form of 
exercise on the nervous system, and yet its potency is shown by 
the increase of red blood-corpuscles and hemoglobin, and Ijy the 
exalted rate and force of the heart-beat without a corresi)onding 
change in the arterial tension. It accomplishes these results by 
decreasing resistance in the peripheral vessels, by the removal of 
the poisons of oxidation, and by mechanically moving the blood- 
4 



50 



EXERCISE IN EDUCATION AND MEDICINE 



current forward in the lymph-spaces and venous channels. It 
thus stimulates the circulation, respiration, nutrition, and ex- 
cretion. 

Mezger gives the best classification of procedures, describing 
four principal manipulations: 

I. Stroking (effleurage), in which the hand is passed lightly 
over the skin,with pressure from the periphery to the center, follow- 
ing the course of the venous circulation and the long direction of 
the muscles from their insertion to their origin. It may be per- 




Fig. 21.- 



-Effleurage of the forearm. Note the distention of the veins above the hand 
that is passing upward. 



formed by stroking with the palm of one or both hands, with the 
thumb or tips of the lingers. The two hands are used upon the 
large fleshy parts of the thighs and buttocks, or upon the chest, 
back, and neck. The thumb is used on small muscles hemmed in 
by bones, such as the interossei of the hand or foot, or the anterior 
muscles of the leg. The tips of the fingers are used around the 
joints of the knee, ankle, elbow, or wrist, the fingers adapting 
themselves to the shape of the part worked upon. The strength 
of the manipulations varies from the slightest touch upon a 
region sensitive to pressure, to the firm pressure with one hand 



MASSAGE AND PASSIVE MOTIONS 



51 



upon the other, over such large masses as the erector spinae. 
Inflammatory products are loosened, passed into the circulation, 
and rapidly absorbed, while the engorged veins and lymph- 
channels are unloaded (Fig. 21). This form is the first employed 
in sprains and freshly inflamed synovial membranes, and in all 
chronic cases where the tissues are matted and sodden, requir- 
ing the absorption of an exudate. 

2. Friction, a firm, deep circular movement performed by 
the thumb, tips of the fingers, or by one hand open or clenched. 
The thumb is employed on the small surfaces of the face or cxtremi- 




Fifj. 22 — Friction of the erector spin;e. 

ties. Friction by the tips of the fingers is used around joints, the 
fleshy part of the thigh, the arm, and the lumbar region requiring 
the entire hand. The friction should proceed in the same general 
direction as the stroking movements, ^^•hich should always follow 
it. The products of fatigue congregating in the deep muscular tis- 
sue are thus thrown into the circulation, the gentle manipulations 
of stroking readily carrying them into the superficial veins. This 
affects all deeply seated structures embedded in muscular masses, 
and should be used along the sciatic nerve in the treatment of 
sciatica and o\'er the alxlomcn to unload the colon. 



52 



EXERCISE IN EDUCATION AND MEDICINE 



3, Petrissage, pinching, or grasping is performed by pick- 
ing up the skin and subcutaneous tissue between the thumb and 
fingers, and manipulating it with an amount of force not sufficient 
to cause pain. In this movement the skin moves with the hand 
of the operator, and the underlying structures are thus massaged 
by it under the pressure of the fingers. It is most advan- 
tageously done by the thumb opposed to the first finger, by the 
fingers opposed to the palm of the hand, or by the two hands 
opposed to one another. The thumb and fingers are used to reach 
individual muscles and small groups, such as the muscles of the 
hand, foot, forearm, and upper arm. The larger muscle masses 




Fig. 23. — Petrissage of the calf muscles. 

of the thigh and calf require the use of the fingers opposed to 
the thumb and hand (Fig. 23), or both hands, the muscle being 
rolled beneath them and pressed against the bone. This has the 
same effect as friction on the deep structures, and is better for sen- 
sitive, easily irritated surfaces, the skin moving with the hand like 
a glove. The movement should always be gradual, proceeding 
from the periphery inward. It is the favorite means used to 
improve muscular nutrition in conditions of fatigue, in atrophy, 
in obesity, or other forms of muscular degeneration. 

4. Striking (Tapotement or Percussion). — This manipulation 
comes under many names, such as clapping, beating, knocking, or 



^ 



MASSAGE AND PASSIVE MOTIONS 



55 



hacking. It is done for small surfaces by patting with the open 
hand, or by slapping with the palm cupped to leave a layer of 
compressed air between the hand and the surface to be manipulated, 
a movement that is familiar to every frequenter of the Turkish 
l^ath. Its action on the skin, superficial nerves, and vessels is stimu- 
lating. Hacking is performed with the ulnar border of the hand, 
and is used along such nerve-trunks as the sciatic or the 
spinal nerves (Fig. 24). Where the bone lies close to the skin, 
at the ankle- or knee-joints or in manipulations of the scalp, this 




Fig. 24. — Tapotement of the l^ack with the uhnar surface of the hands. 



movement should be performed by the tips of the fingers, but over 
the fleshy regions of the thigh and buttocks the clenched hand 
may be used. Each blow stimulates the nerve powerfully and 
causes involuntary contraction of the muscle. When the blow is 
heavy and rapidly repeated, it may even produce local anesthesia. 
The blows should be quick and sharp, but not strong enough to 
bruise the muscle and produce after-soreness. It is commonly 
used in cases of paralysis, neuralgia, and neuritis. 

A fifth manipulation might l^e added — tliat of shaking or 
vibration. Shaking invohx-s mo\'emcnt of the whole body or 
region to be treated, while vibration is a lesser motion in which the 
body or region remains at rest, while the surface and structures 



54 EXERCISE IN EDUCATION AND MEDICINE 

iitimediately beneath it are affected. The term " tremble pressing" 
accurately describes it. These manipulations are so difficult to 
perform skilfully and so exhausting to the operator that machines 
were designed by Zander to replace the inaccurate and rapidly 
tiring human hand. They will be fully described in the chapter 
on Apparatus. 

General massage is best given at an hour midway between 
meals, and never immediately after eating. The order in which 
the manipulations are given is as follows: The parts are first 
lubricated with cocoa-butter or vaselin, to avoid the irritation 
which may follow the friction of a hairy surface. The operator 
starts with the feet, and gently but firmly pinches up the skin and 
subcutaneous tissue, rolling it between the fingers and thumb 
until both surfaces of each foot have been covered. With the 
thumbs and fingers, the small muscles of the foot are kneaded, 
special attention being devoted to the interosseous groups, which 
require slow deep pressure from the thumbs. Care should be 
taken to avoid bruising of muscle and skin against the underlying 
bones. The foot is then grasped and all the natural movements 
of the toes and ankle are rehearsed. Next the region of the ankle 
is dealt with in the same fashion, and stroking movements are 
made from the toes to the leg, to empty the superficial veins of the 
foot. The leg is next treated by circular friction with the fingers, 
by deeper grasping of the areolar tissue, and last by industrious 
and deep pinching of the larger muscular masses, which for this 
purpose are put in a position of complete relaxation (Fig. 23). 
For the large muscles of the calf and thigh both hands act, the 
one contracting while the other lessens its grip. The firm muscles 
in the front of the leg are rolled under the cushions of the finger- 
tips. At brief intervals upward stroking is given from ankle to 
knee, to favor the flow of venous blood-currents. The same process 
is carried on for the hands and the arms. Especial care is now 
given to the muscles of the loins, back, and neck,which are subjected 
to frictions, kneading, and striking with the ulnar border of the 
open hand (Fig. 24), followed by upward stroking of the loins 
and back, the same manipulation being directed downward and 



MASSAGE AND PASSIVE MOTIONS 55 

outward from the head to the shoulders. The abdomen is then 
treated by pinching the skin and underlying tissue, deeply grasp- 
ing the entire muscular walls with both hands, pinching and 
rolling them. Massage of this region concludes with deep knead- 
ing by the heel of the hand in a succession of rapid, deep 
movements passing clockwise in the direction of the colon. The 
chest is then manipulated upward from the sternum along the 
line of the pectoral muscles by pinching and kneading of the 
muscle masses of each side. The face is not usually treated in 
general massage, but the sides of the neck are gently stroked from 
above dowmvard along the course of the internal jugular ^'eins. 
Each part operated upon should be carefully covered after 
treatment. 

Weir Mitchell, in his treatment of neurasthenia by rest, 
overfeeding, and general massage, found a constant rise of tempera- 
ture after each treatment, and noted a rapid improvement in the 
tone and reaction of the whole muscular system. 

The usual fault in giving massage is that too much is given at 
one time — Maggiora's experiments prove that the maximum effect 
on a part is obtained in five minutes. Another mistake is in 
employing too heavy a hand: a patient should never feel bruised 
or exhausted, although a pleasant lassitude is one of the most 
valuable effects. 

Massage should be avoided in certain skin affections, as eczema, 
acne, and other skin eruptions, in wounds, burns, and erysipelas, 
in tumors and purulent inflammations, and in acute disease of the 
bone tissue. It should not be used in the acute stages of se\'ere 
constitutional or local diseases, where complete rest is necessary; 
and it should be allowed only with great precaution in pregnancy 
and in the presence of renal disease. Its place in the treatment of 
sprains, fractures, and other surgical conditions, and its \'alue 
in medicine will be considered more fully in the appropriate 
places. 



CHAPTER IV 

EXERCISE BY APPARATUS 

The application of exercise and massage by mechanical means 
has been considered from two points of view — firstly, from the 




Fig. 25. — The polymachinon of Captain Chiosso. An early attempt at a universal 
exerciser, employing the pully-weight principle. 

standpoint of the physical educator, who would obtain rapid devel- . 
opment of the entire muscular system by specially designed ap- 
56 



EXERCISE BY APPARATUS 



57 



paratus, and, secondly, by the physician who wishes to prescribe 
and control the dosage of exercise in the treatment of disease. 

Both have recognized the law of the "physiological load," 
which afi&rms that a certain resistance is required before a muscle 
can make its maximum contraction. This load is increased if 
the movements are to be few in number and slow in rhythm, and 
decreased for frequent rapidly repeated motions; but some ex- 
terior resistance is necessary; weight must be lifted or moved 
if the best qualities of the muscle are to be developed. 

]Many so-called free exercises, such 
as deep knee-bending, use the body 
weight for resistance. 

Dumb-bells have been used since 
the time of the Greeks for the purpose 
of shortening the period required to de- 
velop a muscular group. Their appli- 
cation is crude and limited, however, 
in comparison to the accuracy and ver- 
satility of machines employing the prin- 
ciple of the lever or the pulley weight. 
The direction of a dumb-bell's pull is 
always downward, whereas, with the 
shoulder attachment of the pulley- 
weight, the drag is lateral, and the high 
attachment of the pulley reverses the 
direction of the force of gravity. By 
changing the position of the pulley it is 
thus possible to isolate the action of all 
the important muscle groups. 

We have records of Captain Chiosso, as early as 1829, at work 
in London, on a machine which he finally perfected and called 
the polymachinon, a portable, closet-like instrument of ropes, 
weights, and pulleys. Among the advantages claimed for it were 
its convenient size, "the space required for it being of so little 
import that it may, with ease, be employed in an ordinary room" — 
and its l^eautv of line, "the elegant and ornamental structure of the 




Fig. 26. — Dr. Sargent's first 
design for the pulley-weight, 
with adjustable weights in 
wooden boxes. 



58 



EXERCISE IN EDUCATION AND MEDICINE 



whole fits it for a prominent position in the dining-room, library, 

or boudoir." 

In spite of these advantages it did not make a permanent 

impression as an exerciser, an article of furniture, or as a means of 
treating the dozen maladies for which it 
was claimed to be most beneficial. 

Other machines, designed on this prin- 
ciple, have been constructed and used for 
the last fifty years, but the improvement of 
their design, their systematic application 
to gymnastic training, and their wide em- 
ployment in physical education are un- 
doubtedly due to the eft'orts of Dr. Dudley 
A. Sargent, of Harvard, who has perfected 
the numerous developing appliances that 
are known by his name, and every gym- 
nasium is now supplied with a more or less 
complete set. 

In its simplest form, the pulley-weight 
shows one pulley attached to the wall at 
the shoulder level, over which runs a rope 
with a handle at one end. The other end 
of the rope is fastened to a weight carrier, 
steadied by guiding rods, which may be 
loaded with iron plates (Fig. 27). This 
rope may be compounded by means of 
another pulley attached to the weight 
carrier, so that its excursion is half that of 
the arm (Fig, 28, A). 
In this way the height to which the weight is lifted is halved, 

allowing twice the range of movement with the same length of 

guiding rod. 

A further elaboration of the pulley-weight uses a floor attach- 
ment, the rope turning about the pulley at the level of the floor, 

making a downward resistance (Fig. 28, B). 

A third variation, called the intercostal attachment, uses 




Fig. 27. — The perfected 
pulley-weight machine 

(Narragansett Co.), with 
weights attached by mov- 
ing a foot lever. Single. 



EXERCISE BY APPARATUS 



59 



the overhead pulley, which draws the arms upward (Fig. 28, C). 
In the triplicate machines all three varieties are used at will 
(Fig. 28). ^, . 




Fig. 28. — Triplex pulley-wfight (Narragansctt Co). 

Attachments are designed for the head, by which the muscles 
of the neck may be developed; also for the foot, to exerci.sc the 
muscles of the leg and thigh. 

The quarter-circle is a modification of the regular pulley-weight 



6o 



EXERCISE IN EDUCATION AND MEDICINE 



machine for keeping the trunk overextended during the arm 
movements. 

Pulley-weight machines have been designed by Dr. Sargent 
for strengthening the flexors of the fingers (Fig. 30), and for the 
pronation and supination of the forearm. 




Others are used for practising the movements of pushing down- 
ward on the parallel bars (Fig. 31) and chinning the horizontal bar. 
In these machines, the bars are set on sliding rods and balanced 
by counter-weights, while the resistance may be increased with 
the strength of the user. They are designed for the man who is 



EXERCISE BY APPARATUS 



6i 







Wi-'i*T^<9B 




^^ 






^^^TBB 


i 


LsS' JH 





Fig. 30. — Finger machine to develop flexors of the fingers and grasping power (Spalding). 




Fig. 31. — Traveling parallel (Xarragansett Co.), invented by D. A. Sargent for develop- 
ing purposes. 



62 



EXERCISE IN EDUCATION AND MEDICINE 



too weak to engage in the heavy exercises on the parallel and hori- 
zontal bars, and, by their assistance, he is enabled to develop 
gradually strength sufficient for the usual feats. 

An ingenious application of the pulley-weight principle is 
shown in an invention by George E. Goldie, in which the body- 
weight replaces the conventional iron plates. The gymnast lies 
upon a padded table running on a sliding frame. Four handles 
are attached to cords, at the top and bottom, so that resistance 




Fig. 32. — Goldie's exerciser in use. By graspinp; the liandlcs beside the feet a 
change in action is obtained. One upper and one lower handle may also be used to- 
gether, and the resistance increased by hooking the frame to a higher rung (Spalding). 

may be obtained from above or below. The upper end of the 
frame is raised and hooked over the rung of a ladder, fixed to the 
wall. Tension on any of the handles draws the table up the inclined 
frame, so that the body-weight is the resistant force. This resist- 
ance may be made as slight as desired by having the frame attached 
to the lowest rung, and may be rapidly augmented by increasing 
the angle of the incline. Nearly all the single movements and 
combinations of the pulley-weight machines may be obtained 
by the use of the upper or lower pair of handles, alternately or 
together. 



EXERCISE BY APPARATUS 



63 



All movements on the pulley-weights must be of the simplest 
character and slow in rhythm. Unless the movement is slower 
than the falling of the weight, a jerky, inefficient action is pro- 
duced. They need but little coordination, and may be repeated 

indefinitely without great mental 
exhaustion. The repeated con- 
tracting and relaxing pumps the 
blood through the muscles, which 
rapidly increase in size, but if the 
entire muscular system be developed 
to its physiologic limit, a very con- 
siderable drain on the vitality is 





Fig. 33. — [■Ixii-cmc muscular de- 
velopment without a corresponding 
increase in heart and lung power. 
This man could not float in sea 
water and died prematurely. Fig. 34. — The nautical wheel in action. 

inevitable. A man may have powerful muscular development 
without a capacity for ])rolonged exertion (Fig. 33). These exer- 
cises should then ])c combined with others requiring skill and 
endurance. 

The simplicity of the mo\-cmcnts is sucli that they are easily 



64 



EXERCISE IN EDUCATION AND MEDICINE 



mastered, and the interest in them soon flags. It needs a strong 
determination, buoyed with the hope of increased strength, to 
continue their use. In order to help the imagination, as well as 
to form a preliminary training for special sports, apparatus has 
been designed to imitate the movements of paddling, rowing, 
sculling, and bicycling, using the principle of the pulley-weight or 
lever. Others employ friction to give resistance to the stroke of 
the oar or the turn of the wheel (Fig. 34) . 

In the inomotor Dr. Sargent has devised a machine capable 
of developing all the muscular system, while allowing the exclusive 
use of selected muscle groups. For this purpose he uses the prin- 
ciple of the lever as applied to rowing and bicycling. The machine 




Fig. 35. — The Sargent inomotor. 

consists of a pair of levers, connected, by four adjustable rods, 
to a sliding seat and foot-rest, which are, in turn, joined by rods 
to a clutch gear or sprocket wheel. 

In the diagram A-B is the framework of steel tubing, L the 
hand lever pivoted at P, F the traveling foot-rest running on the 
track, Pt; S, the traveling seat, moving On the track, St. W is the 
gear or sprocket wheel, connected to foot-rest and seat by rods 
FPR and SPR. The hand lever is connected with the foot-rest 
by rod C, and with the seat frame by rod D. The other important 
parts are the toe straps, Ts, and seat back, Sb. 

After taking his seat, the operator grasps the handles and pulls. 
As he braces his feet the foot-rest moves forward, turning the 
wheel W. At the same time the seat is forced backward by 



EXERCISE BY APPARATUS 



65 



straightening the thighs, and also serves to turn the wheel through 
its connecting rod, SPR. When extension is complete, the second 
half of the movement begins, and the wheel is turned by shoving 
on the handles and pulling the foot-rest and seat toward one 
another by flexing the legs. The power thus obtained may be 
applied to large flywheels, as in the illustration (Fig. 36), or the 
machine may be mounted on rollers geared down so that it 
moves only a few inches for every stroke. In this way the interest 
of a long race may be obtained in a small room. The levers are 




Tlu- SarLjeiU inomolor with flywheel in phice. 



placed eighteen inches apart, allowing the free use of the chest- 
walls in breathing, and so avoiding the rapid onset of breath- 
lessness. If desired, work and rest may alternate in opposing 
groups, development of any desired specialization being thus 
obtained. The general exercise is always sufficiently active to 
give valuable training for the heart and lungs. 

It is capable of infinite variety in its construction and applica- 
tion, either as a stationary piece of developing apparatus, or as a 
means for propulsion on land or water. 



66 



EXERCISE IN EDUCATION AND MEDICINE 



The use of mechanical means for the treatment of disease was 
first systematized and employed in a complete way by Dr. Gustave 
Zander, of Stockholm, about 1857. He there established and 
directed the first Zander institute, and has been actively engaged 
in the practice of medicomechanical gymnastics, lecturing on the 
subject at the medical school of Stockholm until his recent 
retirement, when he was succeeded by his eldest son. 

Zander has devised 
nearly one hundred ma- 
chines to give his exercises 
and manipulations, and his 
system of mechanotherapy 
has enjoyed a wide popu- 
larity in Europe, and has a 
considerable, following in 
America'^ Zander institutes 
are found in Boston, Balti- 
more, Philadelphia, St. 
Louis, San Francisco, and 
elsewhere, while over 
seventy sanatoria are sup- 
plied with some of his 
apparatus. The machines 
are in three series: 

First Series. — Apparatus 
set in motion by the mus- 
cular power of the patient. 
Second Series. — Apparatus set in motion by means of some 
motor. 

Third Series. — Apparatus exercising, by the weight of the 
patient's body or by mechanical arrangements, a corrective pressure 
or tension. They are classified, according to their physiologic 
effects, into four sections: 

I. Apparatus for Active Movements.- — To exercise and develop 
— (a) Arms; (h) legs; {c) trunk, and id) balance. These machines 
are 38 in number. A typical example is Fig. 37, for forearm 




Fig- 37- 



-Machine for flexion and extension of 
the forearms. 



EXERCISE BY APPARATUS 



67 



flexion. Its action may be reversed and used to exercise forearm 
extension. A number of other machines are made reversible, 
a necessary economy that is at once apparent. 

In the balance machine the patient sits astride a saddle- 
shaped seat, grasping a fixed handle-bar. A rolling rotary 
movement is given the seat by motor power, and to preserve the 




Fig. 38. — The "Tower," for respiratory movements. The shoulders are held firmh', 
whMe pressure is applied to the back. 

equilibrium the patient must use all the muscles of the loins and 
abdomen in turn. 

2. Apparatus for Passive Moi'ements. — To manipulate the 
hands and fingers, for chest dilatation, trunk rotation, and pelvis 
elevation. The machine for chest dilatation merits more than 
passing notice. It is called the ''Tower" (Fig. 38), and the 
movement is performed by two crutch-like ai)])liances passing 
beneath the arm-pits, and retracting both shoulders, while the 



68 



EXERCISE IN EDUCATION AND MEDICINE 



chest is thrust forward rhythmically by a cushion applied against 
the back of the patient, as shown in the illustration. The rate is 
set to correspond with normal respiration, and the thoracic walls 
are expanded and stretched by its use. 

3. Apparatus for MecJianical Operations, iiicliidiiig Vihra- 
tioa. Percussion, Kneading, and Friction. — Mbration is gi^'en to 
the whole body by the jolting movement of a saddle-shaped seat 



Fig. 3Q. — The "horse 




vibration of the whole ludy (siiiiiiii; saddleways). 



(Fig. 39), and the Zander vibrator , is adjusted to give about 
500 strokes a minute to the feet, legs, chest, or abdomen. 

Four machines are devoted to percussion: Fig. 40 is pro- 
vided with four beaters for tapotement along the spine. This 
machine has been called the "digitalis of the medical gymnast," 
from its action in slowing the heart-beat. 

One machine is devoted to kneading the abdomen and six 
to friction of the arm, fingers, leg, foot, back, and abdomen. 

4. The ortlwpedic apparatus are eleven in number, and are 
designed for suspension, rotation, and lateral pressure. 



EXERCISE BY APPARATUS 



69 



A comf)lete outfit requires at least 3000 square feet of space, 
with consulting and resting rooms, and a gas engine or other 
motor. 

The resistance is supplied by a weight and lever instead of a 
pulley-weight in all the machines requiring voluntary action from 
the patient. This can be augmented by moving and clamping the 
weight at any point of the graduated scale marked on the lever. 




Fig. 40. — Zander's back percussor. 



They are arranged to comply with Schwann's law of muscular 
contraction, which states that with increasing contraction the 
muscle is able to accomplish less work. The resistance is then 
made to diminish during the latter half of the movement, a ])rinciple 
neglected in all machines whose resistance is furnished by friction 
or elastic traction. In the machine for devcloj)ing flexor power 
of the leg upon the thigh the greatest resistance occurs when the 



70 



EXERCISE IN EDUCATION AND MEDICINE 



leg is bent about 30 degrees from complete extension, this being 
estimated as the point of greatest power in the knee flexors. 

Many objections to the use of duplicate movements may be 
overcome by employing these machines; the amount of resistance 
is always constant, and can be diminished or increased as desired, 
according to the strength of the patient. The dose can be 
accurately prescribed, and the uncertainty of the human hand, 
governed as it must be by the operator's varying physical condition, 
can be eliminated. The amount of resistance forms a curve, the 




Fig. 41. — The Zander vibrator. 

apex of which is at the point of greatest physiologic efficiency, 
thus making it more scientific in its application than the varying 
hand of the operator. 

A number of similar machines were designed by C. F. Taylor 
(1869), and numerous modifications have been made to simplify 
the somewhat cumbersome mechanism of the originals. 

The Zander vibrator gives a rate of from 500 to 900 strokes 
to the minute, but more recent machines carry the rate as high as 
2000 to 5000 strokes. 

There are three types of vibrator now in use: the rigid arm 
vibrator, of which the Zander machine is an example; the flexible 



EXERCISE BY APPARATUS 7 1 

shaft vibrator, and the portable vibrator, attachable to an electric- 
light plug. 

A good machine should be readily adjustable in rate and 
length of stroke, and should be capable of giving percussion and 
a rotary, boring motion. The weight of the vibrator has been 
much discussed, but Eberhart, of Chicago, happily compares them 
to various sized hammers: "If one wishes to drive a small nail, 
he could do so with either a sledge hammer, an ordinary hammer, 
or a tack hammer. The sledge hammer would drive it at one 
blow, but there would be much superfluous power; the ordinary 
hammer would drive it in four or five strokes; the tack hammer 
would possibly require a dozen blows. The final result would be 
the driving of the nail." 

Mechanotherapy has obtained its greatest hold in America 
through the vibratory treatment. The power of properly applied 
vibratory movements to quiet pain, to make a rapid and excited 
heart beat slow and steady, and to reach, through the spinal 
nerves, the deep-seated organs presided over by the sympathetic 
nervous system, is well established. 

Three points must be carefully considered in the application 
of this treatment: (i) The length of the stroke; (2) its rate; (3) 
the amount of pressure. x\ll three can be varied within very wide 
limits, and modified in their effects by the applicator used, the 
chief attachments for a well-designed machine being a rubber 
brush, a ball of hard rubber, and a second ball of soft rubber for 
the throat and for the large muscle masses, like the erector spinte; 
a hollow rubber ball for the treatment of the eye; a flat disc, a 
vacuum cup, and special vibratodes of hard and soft rubber for 
rectum and vagina. The late Maurice F. Pilgrim, in his little 
work on vibratory stimulation, classifies the movements into: 
(i) Stimulation; (2) vibratory stimulation; and (3) vibration. 

Stimulation is produced by a medium stroke and light pressure, 
with the Ijrush attachment, for increasing the Ijlood-supply to a 
region, impro\'ing its nutrition and tone. To produce mild stim- 
ulation, an ap])lication should last from three to seven seconds. 

Vibratory stimulation is aj)plied by the rul^ber l)all with a 



72 



EXERCISE IN EDUCATION AND MEDICINE 



medium stroke and deep pressure, the treatment lasting from eight 
to twelve seconds over one spot. This is recommended for cases 
in which the ^'iscera are to be reached by acting on the spinal 
nerve-roots. 




Fig. 42. — Diagram showing areas in the spinal cord from which the nerves con- 
trolling the various organs and parts of the body are' given off. The red lines in the 
table indicate vasomotor areas. Stimulation of the centers, indicated in the diagram, 
will affect the organs controlled by them, see table at the left of the diagram (Pilgrim). 



Vibration is produced by a heavy stroke and deep pressure 
with the hard-ball attachment. It should not be given for more 
than fifteen or twenty seconds, and is used to inhibit a nerve that 
is giving pain. Pilgrim especially warns operators against over- 
stimulation, which, while not permanently harmful, is never 
considered desirable. 



EXERCISE BY APPARATUS 



73 



The general theory on which this mechanical treatment is 
based is that all functions and organs of the body are controlled 
by certain nerves or nerve-centers located in the spinal cord above 
the origin of the nerve-roots. This "pain organ" (Witmer) 
shows sensitiveness when any disturbance of function exists, and 
painful points are found on pressing over the exit of the controlling 
nerves from the spinal canal. When the nerve is vibrated, the 
painful point tends to disappear, and coincidentally restoration 




Fig. 43. — \'arious attachments recommended for use in the apph'cation of mechan- 
ical vibratory stimulation to the various organs and cavities of the body (Pilgrim): i, 
Rubber brush; 2, rectal and vaginal attachment (rubber); 3, rubber ball; 4, throat attach- 
ment (rubber); 5, eye-cup (rubber). 

to normal action may be expected. The areas of the spinal cord 
containing the origin of the nerves that supply the various organs 
are shown in Fig. 42. 

Case reports show a wide application, and evidences are 
accumulating to prove the usefulness of the Zander machine and 
the more modern vibrators in conditions where this form of 
massage is successfully employed. Their accuracy and control, 
compared with the administration of friction and vibration by the 
hand, need not be dwelt upon. 



CHAPTER V 
THE GERMAN SYSTEM OF PHYSICAL TRAINING 

It is to Germany that modern physical education must look 
for one of the most powerful influences in its development, and 
the somewhat acrimonious discussions that fill gymnastic litera- 
ture, between its supporters and the followers of Ling, the Swede, 
have done much to clarify the principles on which the German 
system is based. 

It is necessary here to review briefly the origin and growth 
of German gymnastics and their introduction to America . 

To BasedoAV belongs the honor of first combining physical 
and mental education in the general training of the European 
youth. In 1774 he founded, at Dessau, the ''Philanthropinum," 
to realize Rousseau's method of nature, "so that the training of 
the mind and body shall serve to assist each other." He em- 
ployed the knightly exercises of riding, fencing, vaulting, and 
dancing in educating the sons of the burghers. He also drew 
his exercises from popular German sports, rowing, swimming, 
skating, and games of ball, and copied from the gymnastics 
of the Greeks, notably the "Pentathlon," which consisted of 
running, jumping, climbing, balancing, and carrying heavy 
weights. 

Among his disciples were Salzman and Guts-Muths, Jahn and 
Spiess in Germany, Pestalozzi and Fellenberg in Switzerland, 
Nachtegall in Denmark, and Ling in Sweden. 

Salzman, one of Basedow's assistants at Dessau, established a 
school at Schnepfenthal, near Gotha, in 1784, and here Guts- 
Muths received his inspiration. As he himself writes: 

"I entered, when still a youth, the school of Schnepfenthal, 
74 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 75 

and thereupon Salzman, its head, conducted me to a place, saying, 
'Here are our gymnastics; within this httle space we amuse our- 
selves daily with five exercises, though they are still in their rudi- 
ments.'" 

It was here that he wrote his first book, entitled " Gymnastics 
for the Young" (in 1793), the first German manual of gymnastics. 
He afterward wrote a book on plays and games, which is still a 
classic, as well as a third on manual training. 

Many private and a few public teachers began to introduce 
gymnastics into their schools, and in 1799 Nachtegall established 
a private gymnastic institute in Copenhagen, at which Ling had 
his first lessons in gymnastics. Guts-Muths had two distinct 
aims, which may be stated in his own words as — " (i) Work in the 
garb of youthful play, and (2) a system of exercise having bodily 
perfection as their aim." 

The first of these principles appealed particularly to Jahn, 
Avhile Ling worked more in the spirit of the second. 

Friedrich Ludwig Jahn was born in 1778, in the village of 
Lanz. He was a man of aggressive, restless, and self-sufificient 
disposition, quick witted, but capricious in his reading. His 
career as a student was Avild and irregular, and, owing to quarrels 
with the members of the student societies at Halle, he became a 
wanderer from university to university. From Halle he went to 
Jena, where he was forced to leave the university and become a 
private tutor, directing his pupils' studies and partaking in their 
sports. His first publication, on the promotion of patriotism, 
appeared in 1800, and showed his tendency to engage in popular 
agitation. For the next ten years he roved about, working at 
his book on German nationality. In this book he extolled the 
value of bodily exercise, and seized upon the idea of making 
physical training a dominant force in national regeneration. 

In the spring of 181 1 he opened his first "Turn])latz" in a 
pine forest on the outskirts of Berlin. Fricsen, whose untimely 
death by assassination he deeply lamented, and others of his 
admirers and pupils, aided in its management. From the first, 
vigorous and war-like games were assigned a leading role, and 



76 EXERCISE IN EDUCATION AND MEDICINE 

special costumes were adopted. Their badge bore the word 
"Turnkunst, " and the figures "g-919-1519-1.811." 



/ 9 \ 
919 

Turnkunst 
\ 181 I / 



These figures served as reminders of Hermann's rout of the 
Roman legions, under Varus, 9 A. d., the introduction of tourna- 
ments into Germany, 919 a. d., the last of the German tourna- 
ments, 1519 A. D., and the revival of "Turnen, " or turning, in 
1811. 

In a year the number of turners rose to 500. Jahn and Friesen 
organized a German union, hostile to all foreign rulers, and ex- 
tended it to the students of various German universities. In the 
war of liberation members of this union were the first men enrolled 
in the famous free corps of cavalry, where Jahn commanded a 
company recruited by himself. 

In the five years preceding 1816 he labored incessantly, writing 
and publishing his book, "Die deutsche Turnkunst, " which sums 
up his aims and accomplishment. In speaking of the beginning 
of his work he says: "Love to my fatherland and my own inclina- 
tions made me a teacher of youth. During the beautiful spring 
of 1810 a few of my pupils began to go out with me into the woods 
and fields on the holiday afternoon of Wednesday and Saturday. 
The number increased at the various sports and exercises. Thus 
we went on until the dog-days, when the number was very large, 
but soon fell off again. But there was left a select number and 
nucleus who held together even during the winter, with whom the 
first turning ground was opened in the spring of 181 1 in the 
Hasenheide." 

In this work he pays willing tribute to Guts-Muths, the main 
source of his inspiration. 

In 1 8 19 plans were perfected for establishing turning grounds 
throughout Prussia in connection with the schools, but because 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 



77 



of a murder committed by one of the turners, to which political 
significance was attached, the student societies and Turnverein 
were put under the ban as being hot-beds of liberalism. Jahn 
was arrested, as well as Francis Lieber, a youth of nineteen, one 
of his oldest and most favorite pupils. Lieber was exiled, and 
chose the United States for his new home in 1827. He came with 
a recommendation from Jahn for the express purpose of taking 
charge of a gymnasium in Boston, where he also established a 
swimming school. 




Fig. 44. — People throwing flowers to the American Turners at the parade which opened 
the Turnfest of 1908, in Frankfort. 

Jahn's case dragged on for nearly six years, but he was acquitted 
in 1825, although with certain restrictions. In 1840 he was finally 
released and awarded the iron cross in recognition of his service 
during the war of liberation. Though he issued many pamphlets 
showing his continued interest in turning, his declining years were 
passed in poverty and obscurity. His last publication appeared in 
1848, entitled "Schwanenrede" (swan song), closing with these 
words: 

"Germany's unity was the dream of my. awakening life, the 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 79 

morning glow of my youth, the sunshine of my manhood, and is 
now the evening star which guides me to eternal rest." 

The formation of gymnastic societies, however, continued to 
grow, and Turnfests were celebrated, until in 1861 nearly 6000 
turners took part in the festivals. 

At present it is as common to find a Turnverein among German 
colonists and peoples of German extraction as cricket and athletic 
sports among Englishmen living abroad. 

The Turnfest at Frankfort, held in July, 1908, had 36,000 
turners in line, drawn from every land to which there has been 
German immigration. America's numbers exceeded that of any 
nation outside of Germany. The hold of turning upon the German 
people was evident by the enthusiasm displayed during the parade 
of the visiting turners on the opening day. Flowers and wreaths 
were showered upon them by the spectators along the route. 

The exercises, which continued for six days, opened by a 
mass drill of about 20,000 men. The illustration shows about 
5000 men rehearsing for this event. Although all the societies, 
drawn from distant lands, had never performed together before, 
the exhibitions were faultless. On succeeding days group com- 
petitions and drills were given by children (Fig. 46) and by 
picked squads representing their societies, with individual and 
group Competitions on the horse, horizontal and parallel bars, 
running, and vaulting. Prizes in the form of wreaths and diplomas 
were given to the successful societies and competitors. 

The turners place great emphasis on mass work, and the social 
side has not been neglected. They have long ceased, however, 
to be political clubs, holding themselves entirely aloof from the 
consideration of party questions. 

They are divided into two main sections: boys from seven 
to sixteen years and men. Classes are subdivided in scjuads, 
each squad being led by a " foreturner, " whose business it is to 
make the members of his squad as expert as possible, and, above 
all, to secure to each an erect form and aggressive carriage of the 
body. 

The introduction of the German gymnastics into the school 



8o 



EXERCISE IN EDUCATION AND MEDICINE 



system was the work of Adolph Spiess, a Hessian, born in 1810. 
He was influenced by Pestalozzi, and trained in the methods of 
Guts-Muths. In 1829 he became acquainted with Jahn, and in 
the following year, while still a student, formed a class of boys at 
Giessen, and made a beginning by teaching what is known as com- 
mon exercises, the simultaneous performance of movements in re- 
sponse to the word of command, either with or without the aid of 
apparatus. He is sometimes called the creator of gymnastics for 




Fig. 46. — A mass drill of school-children at the Turnfest, Frankfort, 1908. 

girls. These gymnastics he introduced into the public schools of 
Burgdorf, in Switzerland, where he became acquainted with 
Froebel. They include free gymnastics, dumb-bell drills, exer- 
cises on the suspended ladder, and see-saw, besides running, 
jumping, and swinging. 

In 1848 he returned to Germany, and at Darmstadt carried on 
special normal classes to train assistants for his work, until his 
death in 1858. He was highly successful in teaching gymnastics 
to the girls of his schools. 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 8 1 

He applied his principle of common or class exercises to the 
apparatus work, as well as to the free movements, and made 
use of music for all suitable rhythmic combinations. His distinct- 
ive work was to systematize German gymnastics and to adapt 
them to pedagogic purposes and methods. 

The problem of training teachers was early recognized, and 
the Royal Central Gymnastic Institute was finally opened in Berlin, 
under the joint control of the ministers of war and education, 
after two unsuccessful attempts. Captain H. Rothstein, of the 
Prussian army, was placed at its head. Rothstein was a warm 
partizan of the Swedish system of gymnastics as developed by 
Ling and his followers, in distinction to the Jahn-Eiselen system, 
and early antagonized the turners by banishing the horizontal bar 
and parallel bars from the institute. This act gave rise to a long 
and bitter controversy in which gymnasts, medical men, and 
university professors took an active part, notably Professor Virchow 
and Du Bois-Reymond, who savagely defended the German 
system and the bars, declaring that if the parallel bars had not 
already been invented, they would be a necessity. In 1862 a 
commission of the most eminent medical men declared that the 
bar exercises, from a medical point of view, should not be excluded. 
As a result of this Rothstein left the Central Institute, and died 
in 1865. 

Gymnastic instruction in the elementary schools was made 
obligatory in 1862 in many of the cities of Germany, and is taught 
by teachers specially educated for this duty, there being now more 
than 1500 trained teachers in Berlin alone. 

The exercises are carefully adapted to the age and sex of the 
pupils. The youngest pupils — from six to ten — engage in a great 
variety of simple games, easy, free movements, marching, jumping, 
and climbing exercises, and the fundamental exercises on the 
gymnastic machines. These exercises grow more complicated 
and difficult for advancing age, and the expertncss of the boys in 
the upper classes is often ({uite astonishing, fencing being taught 
in the upper schools. Singing is almost always combined with 
gymnastic instruction. 

6 



82 EXERCISE IN EDUCATION AND MEDICINE 

Outdoor games have been accorded a place in the German 
system from the first, but interest in them has increased to an 
extraordinary degree from the year 1891, when the Central Com- 
mittee for the Promotion of Youthful and Popular Sports in 
Germany was organized under the presidency of Baron E. von 
Schenkendorff, Facilities for school games have been provided, 
and provision has also been made for their management and 
maintenance. The movement resulting in the American Play- 
ground Association may be traced to the labors of this committee 

and its distinguished president. 
The introduction of Ger- 
man gymnastics in America 
began with the arrival of Dr. 
Follen, a German exile, at 
Harvard, in 1826. The Bos- 
ton Gymnasium in Washing- 
ton Gardens seems to have 
been the first public gymna- 
sium of any note in the United 
States. 

In 1827 Dr. Francis Lieber, 
already referred to, succeeded 
Follen. Gymnastic grounds 
were established at Yale, 
Williams, Amherst, and Brown 
about the same time, while a 

-Typical pose in German wand drill. ^OZCn Or mOrC Schools f ollowcd 

suit. This movement, how- 
ever, was short-lived, and closed about 1830, when both Dr. 
Follen and Lieber left the field and followed other pursuits. 

The subsequent history of German gymnastics in America is 
that of the growth of German immigration and the establishment 
of the Turngemeinden in large American cities, such as St. Louis, 
Milwaukee, Philadelphia, and Cincinnati. The Normal College 
of the North American Gymnastic Union, established in 1861, 
and now conducted at Indianapolis, is employing educated 




THE GERMAN SYSTEM OF PHYSICAL TRAINING 83 

teachers trained in this system by courses extending from one to 
four years, and the official organ of the movement, a monthly, 
called "jNIind and Body," carries on an active campaign to 
introduce physical training into the school system, and disseminate 
knowledge on the subject. 

William A. Stecher, its editor and director of physical education 
in the schools of Philadelphia, divides the German system into six 
large groups or classes: 




Fig. 4S. — T3'pical swing and balance exercise on the parallel bars. 

1. Tactics, embracing marching in all its forms. 

2. Free exercises, embracing all forms with hand apparatus, 
like short and long wands, dumb-bells, rings, and clubs. 

3. Dancing steps, principally for girls, including all the move- 
ments from the simple gallop to the most complicated forms 
executed by expert rlancers. 

4. Apparatus work on the horizontal bar, ])arallcl bars, long 



84 EXERCISE IN EDUCATION AND MEDICINE 

and side horse, buck, suspended rings, ladder, poles, rope, round 
swing, see-saw, balance board, swinging board, pulley-weights, 
storming board, and vaulting table. 

5. Track and field work, such as high, broad, and deep jump- 
ing, hop, step, and jump, running, hopping, putting the shot or 
stone, throwing the javelin or discus, lifting and putting up of iron 
weights and stones, pole-vaulting, swimming, skating, fencing, 
boxing, wrestling, and shooting. 

6. Games and plays, the enumeration of which would take 
too long. The first collection of games was published by Guts- 
Muths in 1793. 




Fig. 49. — Typical circling exercise on horizontal bar. 

The exercises for children are divided into six or eight grades, 
to correspond with the number of years- in the common or grammar 
schools. 

Inclusive as it is of almost all forms of indoor and outdoor 
activity, the characteristic apparatus that wnll' always be asso- 
ciated with German gymnastics, because invented and most 
largely used by them, are the parallel bars, where the typical exer- 
cises are those in which the weight is supported by the arms in 
vaulting and balancing. The horizontal bar, the glorified limb of 
a tree, in which the weight is also supported by the arms in circles 



THE GERMAN SYSTEM OF PHYSICAL TRAINING 85 

and levers; and the vaidiing horse, borrowed from the days of 
chivalry, on which circles, vaults, and pirouettes are practised 
and carried to a high point of development, the weight being 
again supported by the arms. 

Exercise on these machines emphasizes the development of 
the muscles of the shoulder-girdle by the almost constant use of 
the arms in supporting the body weight, and in this, together with 
the large use of music to govern the rate and rhythm of the free 




Fig. 50. — Typical vaulting exercise on German horse. 

exercises done in classes, lies the main difference between the 
gymnastics that are known as "German" and those derived from 
other sources. Singing and turning are inseparable, especially 
with the children, and the system has become more cosmopolitan 
of late years to ht the local conditions and national temperament 
in America. They now may be said to include everything except 
the medical application of exercise and massage, which has been 
left entirely in the hands of the Swedes. 



CHAPTER VI 
THE SWEDISH SYSTEM OF GYMNASTICS 

The Swedish system of gymnastics had its first impulse from 
patriotism, as was the case with the German, but in the hands 
of its scholarly founder it became much more finished as a gym- 
nastic system, and comprises recreative and school gymnastics, 
military gymnastics, and, most distinctive of all, medical gym- 
nastics, or the application of movement to the treatment of disease. 

Peter Henry Ling, its founder, was born in 1776, two years 
before the birth of Jahn, in Smaland, one of the southern provinces 
of Sweden. A dreamy, imaginative boy, he entered, the Latin 
school at Wexio, where he distinguished himself in his classical 
course by his mental ability, strong individuality, unyielding will, 
and reckless enterprise. He was suspended or expelled from this 
school, along with some companions, on account of a breach of 
discipline. Leaving Wexio on foot, he seems to have wandered 
for some years in Sweden, Denmark, Germany, France, and even 
England, acquiring the languages of the countries in which he 
sojourned, and we find him, in 1801, enrolled as a volunteer in 
the naval defense of Copenhagen against the English. Here he 
remained for ten years, becoming a skilled fencer under the 
instruction of Montrichard, a French refugee, from whom he 
obtained a diploma endorsing his ability to give instruction in the 
art. While there he visited and attended the gymnasium of 
Nachtegall, and recognized the national importance of the new 
art, striving to classify and develop its practice according to ana- 
tomic laws and to give it the precision of mathematics. 

In the fall of 1804 he returned to Sweden, to act as a sub- 
stitute for the aged fencing master of the University of Lund, 
whom he soon succeeded. He also taught gymnastics and riding, 



THE SWEDISH SYSTEM OF GYMNASTICS 87 

and applied himself diligently to the study of anatomy and 
physiology, putting his conclusions into practice in the system of 
fencing taught to his pupils. The new exercise became pop- 
ular, and it was not long before interest in it and in his gym- 
nastics spread beyond Lund. Invitations to introduce the double 
art were received from Gothenburg, Malmo, and Christianstead, 
where he gave instruction during the summer vacations in the arts 
of swimming, fencing, the saber, and gymnastics. 

The eight years of his stay in Lund were also fertile in literary 
activity, for it was then that he first began to know and love the 
Scandinavian mythology, and to compose patriotic poems in 
French, German, Danish, and Swedish. About this time he also 
wrote "Agned, " a tragedy in five acts, which was presented on 
the stage at Stockholm. One of his poems, "Gyfle, " deals with 
the loss of Finland, which the Swedes bitterly deplored. These 
plays and poems show the intensity of his patriotism and his desire 
to see his countrymen strong in body and soul, with power to meet 
her enemies. Fervid patriotism was the inspiring motive of his 
poems and his gymnastics alike, though in the latter he saw a 
practical means of restoring the health as well as of developing the 
physique of the race to defend the fatherland. During these 
eight years he thought out the principles upon which his later 
work w^as based, seeking, first, to understand the human body 
and discover its needs, and then to select and apply his exercises 
intelligently with these needs in view. 

He conceived the idea of opening in Stockholm a central 
institute based on the one already in operation in Denmark for the 
training of teachers of gymnastics for the army and school. He 
took as his pattern the institute of Nachtegall, in Copenhagen. 
His plan was successfully carried out, and the school was opened 
in 1814, in the northern suburb, Normaln, on the site occupied ever 
since. Here he equipped the necessary rooms, gymnasium, 
fencing hall, and offices, in some old buildings which had once 
belonged to a cannon factory. By increased grants from the 
Government he was soon furnished with an assistant, and two 
others were added from time to time, until, in 1830, he had three. 



88 EXERCISE IN EDUCATION AND MEDICINE 

Ling believed that gymnastics had a rightful place in education, 
medicine, and national defense, and almost from the start instruc- 
tion was given in these three branches. In spite of a good deal 
of jealousy and opposition he continued to teach fencing and 
gymnastics to the Swedish army, under the sympathetic encourage- 
ment of Bernadotte, who aftervv^ard reigned as Charles XIV. 
When it was shown that the French and Prussian soldiers were 
being drilled in bayonet fencing, his method of teaching this 
exercise v/as investigated and chosen in preference to all others, 
and it became an established part of their regular training. 

In 1836 he published a manual of bayonet fencing for use in 
the army, and another of gymnastics, in which he found it necessary 
to limit the exercises to simple forms that required little or no 
apparatus. 

He commenced the development of medical gymnastics after 
the first year of the Institute in Stockholm, against bitter opposition 
on the part of conservative physicians. 

His school gymnastics comprised only a few stretching move- 
ments, sometimes assisted or resisted by another pupil, but with 
little apparatus, the Swedish educational gymnastics in its present 
form being a comparatively recent growth. 

During all this time his literary activity was intense, and always 
in the realms of mythology and the ancient legendary history of 
the Scandinavian race. His literary labors were rewarded by 
membership in the Swedish Academy, where he also received the 
grand prize. The title of professor was conferred upon him, and 
he was decorated with the Order of the North Star. His collected 
writings fill three large volumes, of which only about 350 pages 
have to do with gymnastics. 

From his first marriage he had one surviving daughter, Jetta, 
and by his second wife, three of his seven children became teachers 
of gymnastics — Hjalmar, Hildur, and Wendla, the first two at the 
Central Institute. In 1839, after some years of impaired health, 
he died and was succeeded at the Central Institute by Branting 
and Georgii, who, in company with Dr. Liedbeck, one of his 
pupils, and husband of his daughter Jetta, arranged his literary 



THE SWEDISH SYSTEM OF GYMNASTICS 89 

remains for publication. The year after his death they pubhshed 
his principles of gymnastics in the incomplete and often frag- 
mentary form in which he left them, a treatise begun as far back as 
183 1. This book, after an opening section devoted to the laws of 
the human organism, takes up in order the principles of edu- 
cational, military, medical, and esthetic gymnastics, and closes 
with a few pages of miscellaneous suggestions and comment. 

Ling's system was constructed in the light of the physiology 
of his day, which often sounds fantastic in the presence of modern 
discoveries. His physiology with regard to the nature of life, the 
laws of organic unity, and the relation of parts seems quaint to 
modern thinkers, and is not easily translated into the scientific 
terms of to-day. His work relating to gymnastics is, however, of 
a thoroughly practical nature, and he must have been a most 
inspiring teacher. He never completely expressed his scheme of 
esthetic gymnastics, and the school gymnastics were the life-work 
of his son Hjalmar. 

Immediately after his death Branting was appointed director, 
a position he retained for twenty-three years. A student of the 
largest medical college in Sweden, a fluent linguist, and a wide 
traveler, he devoted himself with marked enthusiasm to medical 
gymnastics in accordance with the theories of his predecessor, 
and brought that department to a high degree of perfection. He 
insisted that the beneficial effects of exercises were due not alone 
to changes produced in the muscular system, but mainly to the 
influence exerted upon the nerves and blood-vessels — a novel 
view at that time. He also worked out a terminology which, with 
a few changes, is still employed in Sweden. At this period the 
work of the institute began to awaken the attention of other 
countries. Two Prussian army officers. Lieutenant Rothstein 
and Techow, were sent from Germany to Stockholm to take the 
regular course of instruction, and Rothstein afterward wrote 
extensively on the Ling system. His connection witli Ihc Ik'rh'n 
Central Institute has already been alluded to in the ])re\'ious 
chapter. He endeax'orcd to model it on the pattern of the Swedish 
school, but without its department of medical gymnastics. 



go EXERCISE IN EDUCATION AND MEDICINE 

Many other foreigners came for visits of varying duration — 
physicians especially were attracted, among them Dr. Matthias 
Roth, of London, the father of Bernard Roth, F. R. C. S., whose 
work on scoliosis is referred to elsewhere. 

Among the teachers at the Central Institute were Karl August 
Georgii (1808-81), a lieutenant in the army, who became head 
teacher in 1839, giving instruction in anatomy and the three 
branches of practical gymnastics. He published a treatise on the 
Ling method of kinesitherapy and physical education. Three 
years later he removed to London, where for twenty-eight years 
he had a private institute, teaching fencing and school gymnastics 
in addition to his medical work. Here he published, among other 
things, a biographic sketch of Ling, the "new movement cure," 
and a book on rational gymnastics. Branting's successor was 
Colonel Gustave Nyblaeus (1816-1902), under whose directorship 
the course was increased from one year to two years, and practical 
gymnastics finally reorganized, with its three sections, educational, 
medical, and military, each having a head teacher and a second 
teacher. 

John Hartelius (1818-96), a graduate of the institute, who 
afterward completed a course in medicine, took charge of the 
medical gymnastics in 1864. During his term he wrote, besides 
small manuals on anatomy, physiology, histology, and hygiene, 
a larger work on medical gymnastics, which was translated widely. 
He also founded and edited the "Tidschrift i Gymnastics," a 
semi-annual magazine devoted to gymnastics, contributing many 
articles on his own and related subjects. 

To Hjalmar Frederick Ling (1820-86) Swedish educational 
gymnastics is largely indebted for its present form, and the school 
gymnasium for the nature and arrangements of the equipment 
now in use. At first a pupil of his father, he afterward attended 
Claude Bernard's lectures on experimental physiology at the Hotel 
Dieu, in Paris, and lived for a year in Berlin, whither he went to 
introduce the Swedish method of medical gymnastics. After his 
return to Stockholm, in 1864, he was assigned the section of school 
gymnastics. His task was to devise new forms of apparatus 



THE SWEDISH SYSTEM OF GYMNASTICS 9I. 

adapted to the need of the school, and to so arrange them that large 
numbers could exercise at the same time. He largely increased 
the number of useful exercises, and brought them within the reach 
of every pupil. He is the originator of the grouping of exercises 
known as the "day's order," which is so characteristic of the 
Swedish system. Familiar with the whole range of gymnastic 
literature, he was an industrious compiler, and left behind a care- 
fully arranged collection of nearly 2000 pen drawings of positions 
and movements used in gymnastics, all made by his own hand. 
He died in 1886. 

Hjalmar Ling's successor was Lars Mauritz Torngren (1887). 
A third year was now added to the course. His writings included 
a manual of gymnastics for the na\'y and a book on school gym- 
nastics. The second teacher in the section on school gymnastics, 
Major Karl Sillow, has been very active and successful in the work 
of his department, and has made further improvements in the 
construction and arrangement of apparatus. Hartelius was 
succeeded in 1887 by Robert Murray, also a regularly trained 
physician, in the section of medical gymnastics, and Colonel 
Victor Gustave Balck about the same time assumed con- 
trol of the section on military gymnastics. The latter has been 
an ardent advocate of outdoor and other sports for the young, 
and has been active in organizing societies for their cultivation, 
editing a series of a dozen illustrated volumes devoted to a 
description of their various forms. He founded, in 1881, the 
"Sporting Times," and has been the most enthusiastic promoter 
of those popular gyninastic societies that have spread the fame of 
Swedish gymnastics to other countries, accompanying squads of 
his fellow-countrymen to exhibitions in Brussels, Paris, London, 
Copenhagen, and Berlin. He was a member of the committee 
appointed to prepare the new hand-book of gymnastics for the 
Swedish army and na\-y. 

The Swedish gymnastics were introduced into the United 
States by the late Baron Nils Posse through the instrumentality 
of Mrs. Mary Hemenway, and Boston has been the center from 
which their influence has spread. A most active propaganda was 



92 



EXERCISE IN EDUCATION AND MEDICINE 



started by Baron Posse, who lectured and wrote widely on the 
subject, and as a result the Boston Normal School of Gymnas- 
tics was founded in 1889 by Mrs. Mary Hemenway, to provide 




Fig. 51. — Drill in the movements of fencing (Boston Normal School of Gymnastics). 

the means whereby those masters and submasters who desired it 
might make a thorough study of the Ling system for the benefit 




Fig. 52. — A Swedish drill (Boston Normal School of Gymnastics). 

of the schools. This resulted in the introduction of the Swedish 
system of gymnastics in the Boston public schools in 1890, under 
the direction of Hartwig Nissen. After two years' service. Baron 



THE SWEDISH SYSTEM OF GYMNASTICS 93 

Posse resigned and was succeeded by Claes Enebuske, he him- 
self founding a normal school, the Posse Gymnasium, which is 
still carried on by the Baroness in Boston. Both schools give a 
two-year course in both theory and practice, and include a wide 
range of subjects in their curriculum. By a recent arrangement 
the Boston Normal School became a department of Wellesley 
College, thus giving greater facilities for the teaching of outdoor 
sports, which have become an important part of the practical 
work of physical training. Its director is Amy Morris Homans. 
Although Swedish gymnastics have been considerably modified 
by Ling's successors, and particularly by his son, the development 
has closely followed the lines marked out by its originator. 





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Fig. 53. — A game of field hockey (Boston Normal School of Gymnastics). 

His military and medical gymnastics were his most important 
complete accomplishment. He classified movements into groups, 
as they were directed to the muscles of the trunk, head, arm, or 
leg, making use of a table which was the forerunner of the present 
"day's order." His first table consists of three order movements, 
afterward increased to five; then follows, sixth, a leg movement; 
seventh, an arm movement; eighth and ninth, leg movements; 
tenth and ele^•enth, arm movements — all of a respiratory nature. 
His tables also show a forecast of the progression \\hich is the 
other characteristic of the Swedish system. 

His long experience in training military cadets strongly intlu- 
enced the character of his theories. E. M. Hartwell justlv observes 



94 



EXERCISE IN EDUCATION AND MEDICINE 



that Swedish gymnastics still bear witness to their semimilitary 
origin. Ling's peculiar aims are more completely reflected 
and his methods more fully embodied in the physical training 
of recruits and soldiers than in any other department of 
Swedish gymnastics. The military element in Sweden has in 
turn served to add dignity to physical training as a profession, 
and to raise the intellectual and social standing of gymnastic 
instructors. 

The three distinguishing points of the Swedish system of 
educational gymnastics are: 




I'i'l:. 54. — The Royal Guard of Sweden at work in tlic ,u:yninasium (lA-kl)ur 



1. The day's order, 

2. Gymnastic progression. 

3. The use of the word of command for movements instead 
of imitation. 

The exercises of the day's order are always arranged under 
the following ten classes, each of which can be made more difficult 
or complicated, as is deemed advisable by the progress of the 
pupil. The order is: 

I. Introductory exercises, class formations, facings, and 
marching steps (Fig. 55). 



THE SWEDISH SYSTEM OF GYMNASTICS 



95. 



2. Arch flexions, consisting of backward flexions of the trunk, 
executed by the arching of the spine, done either with or without 
apparatus (Fig. 56). 

3. Heaving movements, designed to cuhivate elasticity of the 
chest and increase respiratory power. Usuafly exercises of hanging 
and chmbing (Fig. 57). 





Fig. SS- — Introductory exercise 
position, neck firm. 



Fig. 56. — Arch Qexioii at the 
bars. 



4. Balance movements, or exercises of equilibrium, requiring 
high coordination, rather than force, and especially directed to 
improve the posture of the body (Fig. 58). 

5. Shoulder-blade movements, exercises for the arms, usually 
done in some position producing isolation of the chest and head, 
the object being to raise and widen the chest (Fig. 59). 

6. Abdominal exercises, bringing into play the muscles of the 
abdomen, and by that means acting upon the digestive organs 
and improving the natural support of the viscera (Fig. 60). 



96 EXERCISE IN EDUCATION AND MEDICINE 




Fig- 57- — Heaving movement on ropes. 




Fig. 58. — Balancing exercise. 



THE SWEDISH SYSTEM OF GYMNASTICS 



97 




Fig. 5g. — Shoulder-blade movement. 

7. Lateral trunk movements, consisting of rotation, sidewise 
flexion of the trunk, and exercises derived from these types (Fig. 61) . 




Fij/. ^o. — .\l)domin;ii cxcrrisf on stall Ixirs 



98 EXERCISE IN EDUCATION AND MEDICINE 

8. Leg movements, for the purpose of relieving the engorged 
veins of the fatigued legs (Fig. 62). 

9. Leaping and vaulting over a string or Swedish horse (Fig. 

63)- 

10. Respiratory exercises, accompanied by movements to 

assist respiratory activity. They are designed to restore normal 




Fig. 61. — Lateral trunk movement. 

respiration after the more active work that has gone before 
(Figs. 64, 65). 

This order may be slightly ^•aried by introducing, after the 
balancing exercises, marching and running, or by introducing a 
series of heaving movements after the lateral trunk movements, 
thus increasing the groups in a day's order to twelve. 

The order of exercises is the basis of the Swedish method, and 
may be depicted graphically by the following diagram, repre- 



THE SWEDISH SYSTEM OF GYMNASTICS 



99 




J'ii,'. 02. — Lec; movements. 




Fig. 63. — Leaping exercise. 



lOO EXERCISE IN EDUCATION AND MEDICINE 




Fig. 64. — Respiratory exercise No. i. 




Fig. 65. — Respiratory exercise No. 2. 



THE SWEDISH SYSTEM OF GYMNASTICS 



lOI 



senting a forty-minute lesson period, the height of the curve 
showing the intensity of the effect on the circulation and respira- 
tion. The height of the line for the abdominal exercises is prob- 
ably insufficient in this diagram (Fig. 66). 

Leaping exercises. 







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Fig. 66. 



-Diagram of the day's order, showing the time devoted to each division and the 
amount of effort required for each (Lefebure). 



The apparatus used differs in certain important respects from 
that of the Germans. The parallel bars, horizontal bar, and 
spring-board are eschewed, while the horse is modified in form; 
instead of these are introduced stall bars, boom, climbing ladders, 
and poles, while much use is made of the inclined rope and the 
balancing board. The exercise table or plinth (Fig. 67), used in 
medical gymnastics, is either flat or adjustable to different angles. 

Ling intended that his system of gymnastics should form a 
complete method of physical education, designed to develop all 
the bodily powers, but he did not live to complete his intention. 
In the fragmentary state in which his plans were left, and in which 
they have remained in the hands of his followers, Swedish gym- 
nastics as a complete system are open to the criticism that insuffi- 
cient emphasis is laid upon endurance, and excessive emphasis 
laid on the constant voluntary attention of the pupil. Their 
accuracy makes them peculiarly efficient in correcting the tendency 
of school-children to assume al^normal and hurtful j^osturcs, and 
the stress laid upon the proper carriage and movements of the 



I02 



EXERCISE IN EDUCATION AND MEDICINE 



trunk undoubtedly serve as an antidote to the evil effects of the 
school desk. 

Swedish gymnastics are educational because they are progres- 
sive, definitely arranged according to a fixed law, and require a 
prompt response to the word of command. To be called a com- 
plete system, however, they must include the free outdoor sports 
and games, on which so much emphasis has been laid by Colonel 
Balck, who, recognizing this lack, has done much to correct it. 




Fig. 67. — Gymnasium plinth (Narragansett Co.)- 



In many cases the gymnastic lesson of the Swedish school is now 
replaced by an hour of skating, long walks, or gymnastic games and 
"dancing, and in the training-schools for teachers the introduction 
of dancing steps and other movements to music, which may be 
termed esthetic, is not regarded with the horror that it would have 
excited a few years ago. It may be looked upon as the modern 
development of esthetic gymnastics, w^hich Ling had in mind but 
never worked out. 

The military gymnastics need not be dwelt upon here, as they 
consist largely of fencing with the foil and saber, riding, and other 



THE SWEDISH SYSTEM OF GYMNASTICS IO3 

military exercises, which are not exclusively Swedish in character, 
but the medical gymnastics, which are so widespread in their 
application, deserve a more careful consideration. 

Classification and practice of the movements of massage, 
described in another chapter, have been largely the work of 
Swedish practitioners, and all the duplicate movements were 
described and named by Ling with extreme exactness, so that a 
prescription of exercise may be written with clearness and accu- 
racy. 

All movements have a commencing, intermittent, and ter- 
minating position, the fundamental positions being standing, 




Fig. 68. — Dancing steps to music (Boston Normal School of Gymnastics). 

sitting, lying, and kneeling. In standing there are derivative 
positions of the legs, like flexed standing, or of the arms, like yard 
standing, or the hips firm position, or of the trunk, like curved 
standing. The similar derivative positions are described for 
sitting, kneeling, and lying. 

As these are usually self-explanatory and are employed in 
describing prescriptions in the section on Medicine, no further 
explanation need be made here. 



CHAPTER VII 

THE "SOFT BUSINESS OF JAPAN/' THE "GOSPEL 
OF RELAXATION,^ AND THE "DOCTRINE OF 
CONTRACTION'* 

The rise of Japan to the position of a world's power has brought 
prominently to the attention of western readers an oriental exercise 
which has been elevated to the dignity of a system by some writers. 
It is known as jiu jitsu, or, in its more modern form, jiiido. 

The origin dates back about four centuries, when a certain 
Akiyama went from Japan to China to study medicine. While 
there, he saw a way of fighting called hakuda, consisting of various 
methods of striking and seizing. This he learned; also twenty- 
eight ways of recovering a man from apparent death {kuatsu). 
He began to teach it on his return to Japan, but with so little 
success that he went for help to the Tenjin shrine, and there 
worshiped for one hundred days. One day, while out walking, 
during a snow-storm, he observed a willow, its branches covered 
with snow. Unlike the pine, which stood erect and broke before 
the violence of the storm, the willow yielded to the weight on its 
branches, but did not break. Reflecting upon this principle, he 
began work and invented over 300 different holds, naming his 
school Yoshin-Riu, or the spirit of the willow tree. 

Jiu jitsu is the art of fighting without weapons, and was the 
exclusive possession, until about forty years ago, of the Samauri, 
or swordsmen, of Japan. While it is probably Chinese in origin, 
it was developed in Japan, where it was practised by the Samauri 
for the defense of an unarmed man against a man of stronger 
physique, or one armed with a sword, club, or spear. Its object 
is to place the antagonist at one's mercy by the mere pressure of 
104 



THE " SOFT BUSINESS OF JAPAN 



105 



the finger or hand, to throw him by first disturbing his equilibrium, 
and then yielding suddenly to his struggle to regain it. It also 
enables one to place his opponent's joints in such a position that 
they may be broken by his struggle to free himself. It includes 




Fig. 6g. — Page from a sketch-book of Hokusai (i76o-iiS49) showing: i, Defense 
against a man who seizes your (Keiko-gi) garment by wrist and elbow hold; 2, bending 
the second finger; 3, wrist hold with both hands; 4, finger hold, beginning; 5, finger hold, 
finish. 



numerous methods of taking strangling holds about the neck Ijy 
the hands alone or by grasping the jacket. Some of these hokls 
are shown in the sketch-books of Hokusai as early as 1750. 

The art was jealously guarded by the Samauri, and marvelous 



io6 



EXERCISE IN EDUCATION AND MEDICINE 



tales were told of their prowess in it, but since the abolishment of 
feudalism, forty years ago, the secrets have become common 
property. It is now taught widely in Japan, and is part of the 
physical training of the cadets in the naval and military academies 
under the more modern name of jiudo. Its real merits have been 




Fig. 70. — Page from Hokusai's sketch-book illustrating jiu-jitzu. 



much obscured by the extravagant claims made for it and the 
exploitation it has received in America. 

One of the principal secrets of the art was " kuatsu, " or bringing 
back to life. An illustration (Fig. 71) from an old book on the 
subject will serve to show the principle on which this part of the 



THE SOFT BUSINESS OF JAPAN 



art was based. The spots on the back mark the joints of the 
vertebrae. The point of the middle finger of the right hand is 
placed on the uppermost one, and the heel of the hand is struck 
smartly against the lowest, the left hand being placed on the 
breast. "Thus," the description goes on to say, "you can bring 
him back to life." This is evidently intended for a man who has 
been choked, and is strangely like the procedure of slapping on the 
back for a similar condition, so familiar 
to the Caucasian eye. 

Other illustrations show the knee in 
the hollow of the back, the hands 
brought under the opponent's arms, 
with directions to press on the chest and 
shove with the knee. This and many 
others show varieties of artificial respira- 
tion, but none seem more efficient than 
Howard's, Sylvester's, or Schaeffer's 
methods, as taught to all medical stu- 
dents. Another procedure in the art is- 
the pressing on painful points. This 
was spoken of as the "fatal touch" in 
the years when the secret belonged to 
the Samauri alone. 

In Fig. 72 the black spots show the 
situation of these "fatal" points, and 
pressure is made with the point of the 
thumb or finger, and. in most cases is 
intensely painful. The circle on the 

back of the figure marks the spot in which the knee should be 
placed in the practice of resuscitation. 

In the practice of jiu jitsu blows were delivered by the ulnar 
border of the open hand across the larynx, also gouging, kicking 
in the face or groin, stepping on the arm or leg of a prostrate foe 
so as to break it, and other foul tactics forbidden in boxing and 
wrestling. It was never considered from the standpoint of play, 
but as the last resort of a disarmed man whose life was threatened. 




Fig. 7 1. — Katsu (make alive). 
When a man is killed b\- the 
collar or strangle hold, put j'our 
left hand on his breast and mid- 
dle finger of right on first joint 
of the neck, and with the heel 
of the hand hit the seventh 
joint of the same. Thus you 
can bring him back to life. 



Io8 EXERCISE IN EDUCATION AND MEDICINE 

In its modern form these dangerous blows and holds have been, 
for the most part, eliminated, and in the best known school of 
jiudo, that of Kano, in Tokyo, it is studied not only as a physical 
exercise, but as a moral and intellectual training. 

The course is divided into two parts, called "grades" and 
" undergrades " ; the undergrades are divided into three: A, B, C. 
There are ten grades, proceeding according to the degree of 
training. The teaching in all the higher grades is devoted chiefly 
to mental training and emotional control. Every afternoon many 
hundreds of boys and young men, mostly between ten and twenty 





Fig. 72. — Diagram of the painful spots or "fatal touches" (from an old Japanese work 

on the subject). 

years of age, gather from all parts of Tokyo for practice in the 
spacious hall of the school, its floor spread with thick mats of 
woven grass. 

The constables of the police department are trained in the 
system, and there are now over thirty places where jiudo can be 
learned in Tokyo. 

The art was introduced to America by J. J. O'Brien, who 
became interested in it as inspector of police at Nagasaki, studied 
it, and finally came to America to give pubhc exhibitions and 
private lessons. He modified it considerably, adapting holds to 
European clothing that had been originally designed for the 



THE "soft business OF JAPAN IO9 

Japanese jacket and belt, and using defensive holds against a 
man armed with a pistol, as the Japanese used it against the 
swordsman (Fig. 73). 

In most of the holds and grips the strong and weak positions 
of the joints have been most cunningly considered. If we imagine 
the wrist cut across the middle, to show the position of the tendons, 
it will be seen that, on the back, they are scattered and placed flat 
against the bones, while on the palm they spring out against the 





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Fig. 73. — Jiu jitsu applied to a man armed with a sword. Breaking the elbow and 
taking the sword from him. 

ligament, holding them in their sheath (Fig. 74). The difference 
in the strength between flexion and extension is almost as 2 : i, 
and when the hand has been strongly flexed, even that small 
power of extension is greatly reduced. 

BACK 




PALM 
Fig. 74. — Cross-section of the wrist, showing position of tendons and Ijoncs. 

The object of many of their holds is to force the hand quickly 
into this position of extreme flexion, where it is comparatively easy 
to keep it, and where slight additional pressure produces great 
pain (Fig. 75). 



no 



EXERCISE IN EDUCATION AND MEDICINE 





Fig. 75. — The wrist hold and fall (taken from an old Japanese book). The defense 
given is a kick in the face, delivered when rollin-g over. 

Another favorite Joint on which they work is the elbow. 
The power is applied in one of three ways. The joint, being 
a hinge that locks when the arm is straight, the forearm and 




Fig. 76. — The elbow hold. 



THE "SOFT BUSINESS OF JAPAN III 

arm thus become a long rigid lever, with its weak point at the 




Fig. 77. — Rupture of the anterior ligament following elbow hold. 

center (Fig. 76). If pressure be applied downward, at the wrist 
and shoulder of the extended arm, with counterpressure up- 




Fig. 78. — This hold is got by grasping the enemy's right hand with the left from 
the front, lifting the hand and spinning under the arm to the position shown in the illus- 
tration. This hold is not shown in Japanese books, but was developed from them by J. 
J. O'Brien. 



ward just above the elbow, the anterior ligament will tear and 
the joint become disabled. In most of their holds on this joint 



112 



EXERCISE IN EDUCATION AND MEDICINE 



the man's own weight is used as the downward force at the 
shoulder (Fig. 77). 

In another lock the arm is turned so that the bones of the 
forearm cross into extreme pronation. Power is then applied, 




Fig. 79. — a, Position of the bones, showing the crossing of the radius and ulna and the 
direction of the twist; b, position of the arm when the hold is well taken. 



so that the radius is wrenched out of its socket, or the wrist ligaments 
torn and the arm rendered useless (Figs. 78 and 79, a, h) . 

The principles of these holds are comparatively few and 
simple, but their applications are many and difficult to acquire, 



THE "soft business OF JAPAN" 



even imperfectly. The holds are so arranged as to pass from one 
into another almost automatically, so that if one is successfully 
resisted, the opponent usually struggles into a worse one. They 
are difficult, and even dangerous, to demonstrate with one who is 
unacquainted with their possibilities, because a novice may continue 
to struggle when he should yield, and so do himself serious injury. 
It is most unlikely that a small, 
puny man could, by this means, 
become invincible when pitted 
against a powerful, active ath- 
lete, but with anything like 
equal conditions, it is a most 
valuable means of defense. 





Fig. So. — Position of the 
bones in Fig. 8i. The power ap- 
plied on the hand and upper arm 
prevents straightening of the 
elbow. 



II — 1 - I lid begins by grasping 

the left wrist and hand of the enemy with 
your right and bending the wrist into fle.x- 
jon. To escape the pain he instinctively 
bends his elbow and so jumps into the 
hold, as shown in the illustration. This 
hold was also worked out by O'Brien along 
Japanese lines. 



In its old form it has no place in our calendar of exercises or 
sports, for it was not a game, but rather a way of equalizing an 
apparent disadvantage in lighting, and it could not be classed 
among the forms of exercise to be taught in a school or college, 
unless as an accomplishment or for purely military purj)oscs, like 
the French Sa\-ate (foot boxing), which is combined with the 
bayonet exercise in the military school at Joinville. 



114 EXERCISE IN EDUCATION AND MEDICINE 

In its modern form, as developed by Kano and his pupils, 
these dangerous locks are barred, and trips and throws are almost 
exclusively employed, great emphasis being laid on ways of falling, 
so as to prevent injury from shock of the hard floor or mat. It 
thus becomes like a combination of collar and elbow wrestling and 
tumbling, and, as such, is a distinct addition to our repertoire of 
exercises. 

It is not probable that any great or permanent influence will 
be exercised by jiudo on the methods of physical training in 
America, foreign as it is in origin and aim to Anglo-Saxon ideals. 
Physical education has, however, received distinct contributions 
from other lands besides Germany and Sweden, which have 
appealed to the national temperament and have become absorbed, 
modifying its development to a marked degree. Many of these 
systems or, as Hartwell terms them, " systemettes " have had a 
more or less ephemeral existence, and the main object of some of 
them has been other than the development of the body by muscular 
exercise. 

THE DELSARTE SYSTEM 

Perhaps the best known of these lesser systems is one that has 
been both exploited and maligned, under the name of Francois 
Delsarte, a Frenchman, born at Solesme, in 1811. At the age of 
twelve he was sent to Paris to study painting on china, but his 
tastes carried him in other directions, and he became, in 1825, a 
pupil of the conservatory, a government institution for instruction 
in acting, music, and the ballet. Here he lost his singing voice, 
and, finding himself incapacitated for the stage, he resigned that 
career to study and teach elocution and dramatic art. 

After many years of thought and observation he succeeded 
in formulating what he termed the laws of esthetic science, which 
had, he claimed, the precision of mathematics. Like all enthu- 
siasts, he remained, until his death, in 1871, on the eve of a series 
of discoveries which he felt would revolutionize dramatic expres- 
sion. 

He never published an adequate account of his researches, 
but his scattered and fragmentary notes were collected by Alfred 



THE DELSARTE SYSTEM II5 

Giraudet, of the Grand Opera, Paris, his favorite pupil, and by his 
daughter, Marie (Madame Geraldy), whose tour in America will 
be referred to later. 

Delsarte believed that the perfect reproduction of the char- 
acteristic posture will produce the emotion depicted by the actor, 
and much of his work may be described as an attempt to classify 
and make scientific the empiric rules of the pantomime. Positions 
of the fingers, hands, and legs are named and classified, and the 
expressions of the mouth, nose, and eyebrows are discussed in a 
way that recalls the quaint studies on physiognomy by Levator. 

Gesture as a form of language was his constant study. He 
writes: "When a man says to you, in interjective form, 'I love, 
I suffer, I am delighted, etc.,' do not believe him if his shoulder 
remains in a normal attitude. Do not believe him no matter 
what expression his face may assume. Do not believe him — 
he lies; his shoulder denies his words. That negative form 
betrays his thoughts." 

The system designed by him, and carried on by his immediate 
followers, analyzed form, poise, and gesture in relation to emotion, 
but much of his writing shows the enthusiast and the dreamer. 
His theories were made practical by his strong personal magnetism 
and the social gifts that made him a welcome guest at more than 
one royal table. 

He himself did not elaborate any system of gymnastics to 
develop the body, but he did teach a few principles and exercises 
necessary for stage falling and other maneuvers in acting. 

The work of Delsarte was brought to the attention of Americans 
by his most ardent disciple, Steele Mackaye, who planned to 
bring his master to America to lecture on and demonstrate his 
ideas. Unfortunately, the Franco-Prussian war intervened and 
he died during the Commune. 

His teachings were made into a system of physical culture, 
the motto of which was "relaxation," by Mackaye, Genevieve 
Stebbins, Emily Bishop, Anna Payson Call, and others, and 
when his daughter, Marie, was induced to make a tour in 
America, she found her father's theories so distorted and mis- 



ii6 



exercise in education and medicine 

Criterion of the Hand, 
species. i ^2 



i-II. Ecc.-conc. 3-II. Norm. -cone. 2-II. Conc.-conc. 




I-III. Ecc.-nonn. 




Tonic or power. 



3-III. Nomi.-norm. 




Expansive. 



i-I Ecc-ecc. 




Exasperation. 





Conflict. 



2-III. Conc.-norm. 



3-I. Norm.-ecc. 





2-1. Conc.-ecc. 




Fig. 82. — Delsarte system of oratory (E. S. Werner). 



II 



III 





RECAPITULATION 


. 


2 


' Concentro-concentric. 


Conflict. 


3< 


Normo-concentric. 


Tonic or power. 


I 


. Eccentro-concentric. 


Convulsive. 


2( 


Concentro-normal. 


Prostration. 


3< 


' Normo-normal. 


Abandon. 


I 


. Eccentro-normal. 


Expansion. 


2( 


Concentro-eccentric. 


Retraction. 


3< 


Normo-eccentric. 


Exaltation. 


I ( 


Eccentro-eccentric. 


Exasperation. 



represented that she refused to identify his name with the move- 
ment, and colifined her attention to giving semiprivate lectures 



THE DELSARTE SYSTEM 



117. 




and parlor entertainments in elocution and the interpretation of 
Lafontaine's fables according to the rules taught by him. 

In its Americanized form, the so-called Delsarte method had 
a great vogue in schools for young ladies and in society, and it is 
largely through the writings of Genevieve Stebbins, Anna Payson 
Call, and Mrs. Bishop that it has been called "the doctrine of 
limpness." Here is a typical 
exercise from Emily Bishop's 
book, "Americanized Delsarte 
Culture": 

" Hold some thought of tran- 
quillity, sitting erect, so that the 
feet easily rest upon the ground. 
Look steadily at some point in 
the ceiling, and take five slow 
deep breaths. Let the eyelids 
droop heavily and the head sink 
gently, the chin resting upon the 
chest. The back relaxes as far 
as possible, vertebra by vertebra. 
Last of all, the hip-joint relaxes, 
causing the head to sway forward 
until it reposes in the lap. In 
returning to the original position 
reverse the order of action. The 
hip-joint acts first, the motion 
creeps up the back, until the 
spinal column regains its double 
curve, which lifts itself to its nor- 
mal poise, after which the eyelids 
languidly open, as they do in babies when a little one seems 
unwilling to surrender to hea\y drowsiness. 

''This exercise secures a threefold benefit: It develops sin- 
gleness of attention; it partially stupefies the brain, and directly 
soothes the nerves. Aff'ect the spinal column in any way, and the 
entire nervous system sympathizes. When accurately done, it 



Fig. S3. — The right and wrong ways of 
raising an arm according to the Delsar- 
tian teaching of relaxation (Cassell's 
"Physical Educator"). 



Il8 EXERCISE IN EDUCATION AND MEDICINE 

always produces a sensation of sleepiness. It is, however, difficult 
to get the controlled even motion that is essential to tranquillize 
the nerves. This usually requires considerable practice under 
the direct attention of a teacher. Such an exercise should occupy 
from three to five minutes. From three to five repetitions should 
produce drowsiness sufficient to make one unreservedly relax 
and sleep." 

Anna Payson Call, who also preaches the gospel of relaxation, 
emphasizes self-suggestion to overcome the chronic condition of 
nervous tension so frequent among American women, and it is 
this thought that has been a real contribution to physical education. 

Delsarte may be said to have been the greatest influence in 
directing attention to economy of muscular action in expressing 
thought, and his principles continually crop out in such schemes 
of gymnastics as that of C. W. Emerson, given in connection with 
his school of oratory. While he has a comparatively small number 
of exercises, without apparatus, he insists on their continual 
repetition, with the purpose of perfecting each one. The points 
upon which he chiefly insists are the active position of the thorax, 
the spine erect, and the abdomen drawn in. He speaks much of 
the poise and balance and graceful control of the limbs. 

The benefit of such exercises is not to be questioned, particu- 
larly in slight cases of prolapse of the viscera, where the chest is 
collapsed and the abdomen protrudes. 

THE DOCTRINE OF CONTRACTION 

As if to offset this "gospel of relaxation," a number of systems 
have sprung up, built on the doctrine of intense simultaneous 
contraction of as many muscles as possible in performing a simple 
movement. 

Sandow endeavored to found a system for complete develop- 
ment on this doctrine, using the spring dumb-bell (Fig. 84), an 
instrument of his own invention, which required continuous con- 
traction of the grasping muscles to compress the spiral springs 
separating the two halves of the handle. 

Macdonald Smith, in England, has his system of "full con- 



THE DOCTRINE OF CONTRACTION 



iiQ 



tractions" for rapid development of the entire muscular system, 
but it is in connection with the "correspondence schools" of 
"physiologic exercises," whose alluring promises and attractively 
illustrated advertisements have decorated the magazines for the 
past few years, that the doctrine of contraction has had its widest 
publicity. In a circular sent by one the writer begins by stating 
that "all movable parts of the body have muscles to move them 
one way, and also have muscles to move them back again," so 
that by using one muscle or group to resist the action of its antago- 
nist, the same development can be reached as by the use of weights. 
It is claimed that the alternate contractions and relaxations help 




Fig. 84. — Sandow's spring dumb-bell. 

the venous circulation, and instead of obstructing the circulation 
of the capillaries, would accelerate the blood in its course toward 
the heart. The use of one muscle to antagonize another is the 
principle upon which this and other systems are built. 

A typical exercise would be the simple flexion and extension of 
the arm, during which the attention is concentrated on the flexors 
of the arm (Fig. 85 j. The fist is tightly clenched, and the arm is 
slowly flexed with intense resistance from the lengthening triceps, 
so that during the movement the entire arm is in a state of tension. 
To increase the effect the subject stands with knees everted and 
slightly bent, and the muscles of the thighs in vigorous contraction. 



I20 EXERCISE IN EDUCATION AND MEDICINE 

The exercises are never complicated or elaborate. They are 
usually simple, definite, clearly described, and illustrated. 
Although there is little originality in their design, there is a novelty 
in the manner of their statement that appeals to the uninformed 
and partly informed with the force of a new truth. 

The advantage of such movements to a business man who is 
not ambitious to excel in games or sports, but who wishes to get 




Fig. 85. — Fle-xion of arms with resistance of the extensors and contraction of the thigh 

and leg muscles. 

his necessary exercise in "tabloid" form, is evident, and it is to 
him that such a proposition makes its appeal. Great numbers 
can be treated at their homes, through written directions sent by 
mail, and ephemeral institutions are formed in the business sec- 
tions of cities and filled with patients by a personal canvass 
from office to office. Twenty minutes daily of this intense work, 
involving the large muscle groups of the legs, trunk, and shoulders, 
powerfully stimulate the heart and respiration, draw the blood out 



THE DOCTfRINE OF CONTRACTION 121 

to the extremities, and cause profuse perspiration. When followed 
by a shower-bath and a rub-down, it produces the same good 
effect, both physically and psychically, that would be derived from 
an equal amount of other exercise. Increased strength of a 
certain kind is sure to follow such a course, a strength to grip 
or to lift, and the drudgery of it is not without its good points. 
These exercises will quickly develop the muscles, and they 
interest for a time many who would not otherwise take any 
form of exercise. Their utility to cultivate the qualities most 
useful for the habitual muscular movements of every-day life, and 
their ability to give all-around development, is another matter. 
In this respect they do not stand the test well. In such a course 
there are no movements requiring fine or complicated coordination, 
and there are none that aim at the acquirement of skill or dexterity. 
For a man who wishes to excel in playing a game like golf, tennis, 
or any other game requiring lithe, graceful, and accurate motion, 
these exercises are not only valueless, but detrimental. They 
make him muscularly self-conscious, and break up that fine adjust- 
ment of coordination so necessary for quick, strong, unerring 
movements. They ignore the law of muscular relaxation and 
economy of energy essential to the precise and graceful accomplish- 
ment of any muscular act, and they overlook the importance of 
the free and far extension of the extremities characteristic of such 
actions as throwing, thrusting, and striking, so necessary to 
counteract the constant posture of flexion produced by sedentary 
occupations. The strain put upon the circulation by this excessive 
contraction is also great, and may overstrain a heart organically 
weak or encumbered by deposits of fat. 



CHAPTER VIII 
AGE, SEX, AND OCCUPATION 

Growth and development are directed by the play instinct, 
an automatic system of physical education. While the man-made 
systems that have just been described can be successfully brought 
into requisition at the later stages of a child's progress to maturity, 
they are comparatively insignificant and his neuromuscular 
development is principally due to spontaneous exercises of his 
own creation. 

To be effective, physical education must travel along the same 
road as that naturally used by the growing boy or girl, unhampered 
by artificial conditions. 

The first movements of the infant consist of spontaneous 
kicking and squirming, with aimless motions of the arms, hands, 
and head. As he progresses, more complicated movements are 
introduced — the picking up and dropping of objects, digging and 
piling up sand, and playing with blocks and other toys. Movements 
of equilibrium — creeping, learning to walk and jump — are soon 
followed by the boy's interest in throwing and cutting with a knife. 

About the age of seven, catching and all games of ball begin to 
engage his attention, with individual games like tag, hide-and-seek, 
leap-frog, and other tests in which his awakening powers are tried, 
but it is not until the age of twelve that the boy begins to find 
his medium in the competitive games — those games demanding 
the sacrifice of the individual to the team. 

This law is graphically shown by Dr. Luther Halsey Gulick in 
the accompanying chart, in which the plays of the Anglo-Saxon 
boy are tabulated. 

His life is divided into three periods — from birth to seven, 
from seven to twelve, and from twelve to maturity. The spaces 
inclosed by the curved lines include the games that are acquired 
at each stage, and also those that are retained to a more advanced 
age. These lines must not be considered as final, since, in many 



AGE, SEX, AND OCCUPATION 



I23_ 



individuals, the beginning of interest in any play may be earlier 
or later than the time stated, and in all children they begin grad- 
ually and shade off just as gradually. As age progresses they 
drift from plays that center in the individual to plays in which he 
considers himself related to others. Growth is accompanied by 

Birth 
Anglo-Sason Boys' Plavs. 
(Neuro-Muscular.) 

Whole arm, body 
nd hand movements. 
Dropping things. Blocks. 
Sand Plays, digging, piling, etc. 
Running, throwing, cutting and fold- 
ing. Swinging. 

Shooting, guns, bows, slings, etc. 
Knife work. Tools of increasing 
complexity. 



Machinery 
Sailing. 
Rowing. 
Swimmiog. 



Tag. 
Cross tag. 
Word tag. 
Prisoner's 

base. 
Hide and 

seek. 



Gymnastics. 
Indian Clnbs 
etc. 



Ball 
games. 
One old cat. 
Throwing. 
"buck on Fungo. ^^^ 

, -ocv Rounders, „, , 

^ J rocK. Black man. 

Leap frog. ***^- 

7Va<rA<j«rf ■^'^'■W^i-axw.f. "Stunts," 
Field Sports. ^^'^' C'nts, hole, etc. 
Foot-ball games. Care of 

land and animals. ^^^" Baseball. 
Hunting, fishing. j^ Basket-hall. 
War. Wrestling, ^r Cricket. 
Boxing, fencing. X Hockey. 

Predatory. / Gangs. 

Billiards. / Houses in woods. 

Bowling. / Pals. 

Predatory gangs. 
Hero service. 



X.VTBEa GlTLICK, 



Fig. 86. 



-Luther Gulick's table, showing the age at which various games and sports 
begin, are most popular, and wane in interest among boy?. 



an increased complexity in the movements required, and in the 
third division, beginning approximately at the age of twelve, the 
start of what is termed the "gang" instinct is seen — boys con- 
ducting their sports in groups and teams, team work being the 
keynote of this group, as individual excellence was of the preceding. 



124 EXERCISE IN EDUCATION AND MEDICINE 

It must not be forgotten, however, that the games acquired in the 
second period also persist, and often dominate the boy throughout 
his entire growth. Guhck has pointed out that savages who have 
reached the stage of cooperation required for fighting under a chief 
in organized tribes are really doing what the Anglo-Saxon boy 
does at the age of twelve. All the higher forms of sport involving 
team-work and specialization are merely a physical expression of 
the law of evolution that governs the business and social life of a 
civilized community. 

In outlining a course of physical education the first considera- 
tion must always be given to this law of physical evolution. The 
formal gymnastics have no place among the young child's physical 
exercises, but his natural plays and games are developed and used 
educationally for his physical welfare. 

Froebel recognized this fundamental law and developed it into 
his kindergarten. 

Until the age of twelve there is but little difference in the spon- 
taneous play of boys and girls, but with the consciousness of sex 
and the accelerated growth of puberty their interests rapidly diverge. 
Girls retain their individualism, and do not come under the 
domination of the "gang" instinct to the same extent as boys. 
Their interest turns to more feminine accomplishments, requiring 
grace and lightness, and much pleasure is found in dancing in all 
its forms and in gaines in which rhythmic movement is prominent. 

It is not until a comparatively mature age physically that the 
more formal gymnastics can be introduced and their correction 
applied to the confinement of school, shop, or home life. The 
games accompanying them must also be chosen with reference to 
the natural desires found in normal children of that age. 

During adolescence, sports and games play so large a part in 
physical development that a definite classification of the outstand- 
ing effects of the most familiar of them is given in the table (pp. 
126, 127) for guidance in their selection.. 

It is impossible to give any great degree of exactness to such a 
ta:ble without cumbering it with wearisome explanations. In a 
familiar exercise like walking the change in speed from three to 



AGE, SEX AND OCCUPATION I25 

five miles an hour will elevate an automatic, listless occupation 
into a A'igorous exercise, employing many new muscle groups and 
stimulating the heart, lungs, and skin, while the change from a 
smooth level road to the broken ground of a mountain side may 
be dangerous for one who might walk at moderate speed on le^•el 
ground. 

The muscles employed are named approximately according 
to the intensity and the duration of their action; the notes in the 
column marked "demand on the nervous system" refer to the 
concentration required, its degree varying with the difficulty of 
the movement. The "influence on respiration and circulation" 
of an exercise is indicated by the onset of breathlessness and 
increase in the blood-pressure and pulse-rate during its practice. 

The chief characteristics cultivated by the constant repetition 
necessary for success in such games come in the fourth column, 
and the age limits within which they should be contained are 
placed in the last but one. The time of life for beginning and 
leaving off any exercise must vary greatly with the individual, 
but the ages mentioned are not far out for the average man. The 
upper age limit in all cases is placed at sixty. If, by that time, a 
man has not determined what form of exercise is most suitable 
for his condition and constitution, he is not likely to be capable 
of receiving guidance from this chart. 

Striking examples are continually quoted of exceptional men 
who have long passed the "dead" line and are still active in such 
sports as cricket, baseball, and boxing. If indulgence in a sport 
has been continued with regularity, a man's own feelings as to 
when it must be abandoned are better indications that any fixed 
rule. It is dangerous, however, for any elderly gymnast to attempt 
his youthful feats after a long interval of idleness and disuse. How- 
ever long he may have lain fallow, he is often unwilling to accept 
the limitations of his years. This danger was once strikingly illus- 
trated to me on the person of an authority on gymnastics who, in 
attempting a simple feat with which he had been familiar, strained 
the muscles of his neck so badly that he was incapacitated for 
several weeks. 



/ 



126 



EXERCISE IN EDUCATION AND MEDICINE 



CLASSIFICATION OF ATHLETIC GAMES AND EXERCISES. 









Influence 












Demand 


on pulse, 


Physical 


Best 




Exercise. 


Chief regions of the 


on nerve 


blood- 


character- 


age for 


Remarks. 




body used. 


control. 


pressure, 
and res- 
piration. 


istics culti- 
vated. 


prac- 
tice. 




Baseball. 


Right or left fore- 
arm, shoulder, and 
the whole muscular 
system to a lesser 
degree. 


Great. 


Moderate. 


Accuracy, 

speed, and 

agility. 


12-30. 


Amount of exercise 
depends on the posi- 
tion played; pitcher 
has his pitching arm 
constantly v e r - 
worked. 


"Bowling. 


Right forearm, arm, 
shoulder, and back. 


Great. 


Slight. 


Accuracy 

and 
strength. 


14-60. 




Boxing. 


All of forearm, arms, 
shoulders, chest, 
back, and thighs. 


Extreme. 


Great. 


Alertness, 

agility, 
strength. 


16-40. 




Cricket. 


The whole muscu- 
lar system mod- 
erately ; right or 
left forearm, arm, 
and shoulders. 


Great. 


Moderate. 


Accuracy, 

speed, and 

agility. 


12-60. 


Depends on position 
played; exercise ob- 
tained by bowler is 
different from that 
of the fielder. 


Cross coun- 


Thighs and legs. 


Slight. 


Extreme. 


Endurance, 


18-25. 


A severe test of the 


try running. 








speed, and 
strength. 




heart. 


Dancing. 


Thighs and legs. 


Extreme. 


Great. 


Endurance 

and 

agility. 


14-40. 


Clog and soft shoe 
exercise only the 
legs, but many acro- 
batic postural and 
esthetic dances 
bring in the trunk 
and arms. 


Football. 


Thighs and legs. 


Moderate. 


Great. 


Agility, 


12-35- 


In this game the ball 


(seeker). 








speed, and 
strength. 




is not touched b y 
the hands, b u t i s 
kicked by the feet 
and butted by the 
head only. 


Football. 


The whole muscu- 


Extreme. 


Great. 


Accuracy, 


16-30. 


The most severe field 


(Rugby). 


lar system. 






endurance, 
speed, and 

agility. 
Accuracy. 




game on the heart 
and lungs. 


Golf. 


The whole muscu- 


Extreme. 


Slight. 


12-60. 


The walking inter- 




lar system moder- 










rupted by the 




ately. 










strokes of the game 
make it peculiarly 
valuable for those 














living a sedentary 
indoor life. 


Hammer- 


Shoulders and back, 


Extreme. 


Slight. 


Accuracy 


16-50. 


A difficult feat of co- 


throwing. 


also arms and 
thighs to a lesser 
degree. 






and 
strength. 




ordination as now 
practised, i. e., from 
a 7-foot circle. 


Hand-ball. 


The whole muscu- 
lar system, par- 
ticularly the back. 


Great. 


Extreme. 


Accuracy, 

speed, and 

agility. 


12-40. 




Hockey. 


The whole muscu- 
lar system, espe- 
cially the back 
and right (or left) 
forearm. 


Extreme. 


Extreme. 


Speed, agil- 
ity, accu- 
racy, and 

endurance. 


12-25. 


An extreme test on 
the heart and lungs. 


Hurdling. 


The whole muscu- 
lar system, espe- 
cially the abdom- 
inals, thighs, ham- 
strings, and calves. 


Extreme. 


Great. 


Speed, agil- 
ity, and 
endurance. 


16-25. 


The high hurdles 
(3 ft. 6 in.) require 
great accuracy. 


Jumping 


Thighs, lower back. 


Extreme. 


Slight. 


Agility and 


14-25 1 


Jumping without a 
run cultivates agil- 
ity only. 


(high). 
Jumping 


and shoulders. 
Thighs, calve, back. 


Great. 


Slight. 


speed. 
Agility and 


1 
14-25 (' 


(broad). 


and shoulders. 






speed. 


J 


Lacrosse. 


All the muscles of 
the legs and arms. 


Great. 


Extreme. 


Speed, en- 
durance, 

agility, and 
accuracy. 


12-30. 


A running game. 



AGE, SEX, AND OCCUPATION 



127 









Influence 












Demand 
on nerve 
control. 


on pulse. 


Physical 


Best 




Exercise. 


Chief regions of the 
body used. 


blood- 
pressure. 


character- 
istics culti- 


age for 
prac- 


Remarks. 






and res- 


vated. 


tice. 










piration. 








Mountain- 


Thighs, legs, and 


Slight. 


Extreme. 


Endurance. 


16-40. 


A severe test on the 


climbing. 


back. 










heart and lungs, 
particuhirly in high 
altitudes. 


Pole- 


Forearm, arms. 


Extreme. 


Slight. 


Agility and 


14-25. 




vaulting. 


shoulders, abdo- 
men, thighs, and 
legs. • 
Back, abdomen, 






strength. 






Riding 


Slight. 


Slight. 


Balance. 


14-60. 


The mechanical shak- 


(horseback). 


and thighs. 










ing has a distinct 
therapeutic effect. 


Polo(pony). 


Right or left arm, 
back, abdomen, 
and legs. 


Extreme. 


Great. 


Accuracy, 

balance.and 

strength. 


16-30. 




Running, 


Whole muscular 


Extreme. 


Great. 


Speed and 


12-30. 


A typical exercise of 


100-200 yds. 


system, especially 
the thighs and 
calves. 






alertness. 




effort. 


Running 


The whole muscu- 


Great. 


Extreme. 


Speed and 


17-25- 


A severe test on the 


440-1000 


lar system e.xcept 






endurance. 




heart and lungs. 


yds. 


the arms. 












Distance 


Thighs and calves. 


Moderate. 


Extreme. 


Endurance. 


17-25- 


A severe test on the 


running (i 












heart and lungs. 


mile and up- 














ward). 














Rowing. 


Back, forearm, arm 
flexors, shoulder 
muscles,and thighs. 


Slight. 


Extreme. 


Strength 

and 

endurance. 


16-40. 


Thighs are practi- 
cally unused, except 
with the sliding seat. 


Shooting 


The whole muscu- 


Slight. 


Moderate. 


Endurance. 


16-60. 


Value depends on 


(hunting). 


lar system, espe- 
cially the thighs, 
legs, and back. 










tramping over ir- 
regular ground and 
open air. 


Target. 


The whole muscu- 
lar system, very 
moderately. Arm 
flexors and all of 
forearm. 


Extreme. 


Slight. 


Accuracy. 


14-60. 




Shot- 


Right (or left) fore- 


Great. 


Slight. 


Strength, 


16-50. 




putting. 


arm, triceps, shoul- 
ders, back, and 
thighs. 






speed, and 
agility. 






Swimming. 


The whole muscu- 
lar system. 


Moderate. 


Great. 


Endurance 

and 

strength. 


12-60. 


Racing and diving 
are extreme tests on 
the heart and lungs. 
Swimming for dis- 
tance at a moderate 
speed is a test of 
endurance and 
starnina. 


Tennis. 


The whole muscu- 
lar system, espe- 
cially right (or 
left) forearm and 
arm. 


Great. 


Moderate. 


Accuracy, 
speed, agil- 
ity, and 
endurance. 


14-40. 


Tennis - elbow is 
caused by constant 
repetition of back- 
hand stroke, pro- 
ducing strain of pro- 
nator radii teres 
muscle. 


Walking. 


Thighs, legs, and 
back. 


Slight. 


Moderate. 


Endurance. 


16-60. 


Two to four miles 
an hour is mild exer- 
cise. Four to six 
miles may be ex- 
hausting, if kept up 
very long or if road 
is rough. 


Water polo. 


Whole muscular 
system. 


Extreme. 


E.xtreme. 


Endurance, 

strength, 
and agility. 


16-25. 


An extreme test of 
the heart. 


Wrestling. 


Whole muscular 
system, especially 
neck, back, arms, 
shoulders, and ab- 


Extreme. 


Great. 


Strength, 

endurance, 

agility, and 

speed. 


16-40. 






domen. 













128 EXERCISE IN EDUCATION AND MEDICINE 

From the standpoint of therapeutic effect, or even of rapid 
development, most athletic games are inaccurate and wasteful 
of time. For these purposes they do not compare with the accurate 
movements of formal gymnastics. During a baseball game an 
outfielder may spend four-eighths of his time standing with his 
hands on his hips, another three-eighths sitting on the bench, and 
the remaining one-eighth at the bat, on the bases, or in the practice 
of throwing the ball. For an expenditure of two hours or more 
he gets nothing but fresh air and a little exercise for his right arm 
and shoulder. In a game of foot-ball the time occupied in actual 
play is only four or five minutes, the rest of the time being spent 
in discussion, disentangling the team after a play, and in preparing 
for the next play, the exhaustion following a game being largely 
nervous. 

Games and gymnastic exercises especially designed for a spe- 
cific purpose can be applied to remedy defects or weakness more 
quickly and surely than sports whose object is recreation alone. 
No game growing up in a community of children could teach 
alertness like Dr. Sargent's "curtain ball," a game in which two 
courts are separated by a curtain eight feet high, each side attempt- 
ing to throw a basket-ball so as to touch the floor of its opponent's 
court and at the same time defend its own from a similar fate. 

Gymnastic apparatus was originally made to imitate the tools 
and appliances of the outdoor world. The horizontal bar was at 
first the branch of a tree, the climbing pole a mast, and the ropes 
its rigging. The wooden horse of the gymnasium dates from the 
days of chivalry, but the agile and complicated movements that 
give it interest and value would be impossible on its living proto- 
type. Many of the exercises on the horse would indicate that 
it also represents a log on which to balance and from which to 
leap. 

In the following table the main characteristics of the more 
familiar pieces of gymnastic apparatus are classified as they were 
in athletic srames. 



AGE, SEX, AND OCCUPATION 



129 



CLASSIFICATION OF 



GYMNASTIC APPARATUS, EXERCISES, AND 
GAMES. 







Demand 


Influence 




Ap- 
proxi- 
mate 
age 




Exercises. 


Chief regions of the 
body used. 


on ner- 
vous con- 
trol and 


on blood- 
pressure, 
pulse, and 


Phy.sical 
qualities 
cultivated. 


I.emarks. 






coordi- 


respira- 




limit. 








nation. 


tion. 


Agility, ac- 


16-30. 




Basket- 


The whole mus- 


Extreme. 


Extreme. 


An exlreme test on 


ball. 


cular system, es- 
pecially legs, 
thighs, and lower 
trunk. 






curacy, and 
endurance. 




the heart. 


Bom 


Flexors of fingers. 


Moderate. 


Slight. 


Strength 


16-40. 




(Swedish). 


wrist, and fore- 
arm, flexors of 
arm, all of shoul- 
der, and abdo- 
men. 






and 
balance. 






Buck. 


All of forearm, 
arm, and shoul- 
ders; thighs, and 
legs. 


Moderate. 


Slight. 


Agility, bal- 
ance, accu- 
racy, and 
precision. 


12-40. 


Thighs and legs ex- 
ercised principally 
during approach 
and finish of move- 
ment. 


FlyinK 


Flexors of hand, 


Great. 


Moderate. 


Strength, 


16-30. 




rings. 


wrist, forearm, 
arm, shoulders, 
and abdominals. 






rhythm, 

and 
balance. 






Horizontal 


Flexors of fingers, 


Extreme. 


Moderate. 


Strength, 


16-30. 




bar. 


wrist, forearm, 
arm, pectorals, la- 
tissimus dorsi, and 
abdominal mus- 
cles. 






balance, 

and 
rhythm. 






Horse 


All of forearm. 


Moderate. 


Moderate. 


Agility, bal- 


14-30. 


These exercises are 


(long). 


arm, shoulders, 
abdomen, thighs, 
and legs. 






ance, and 
strength. 




vaulting and leap- 
ing, and so de- 
velop thighs anil 
legs more than side 
horse. 


Horse 


All of forearm, arm. 


Extreme. 


Slight. 


Balance, 


12-40. 


Thighs and legs de- 


(side). 


shoulders, abdo- 
men, thighs, and 
' legs. 






accuracy, 

rhythm, 

agility, and 

strength. 




veloped in the ap- 
proach and finish, 
but much less than 
arms and shoul- 
ders. 


Ladders. 


Flexors of fingers, 
wrist, forearm, 
arm, i.ectorals, 
and latissimus 
,1, 1. ■; 


Slight. 


Slight. 


Strength. 


14-60. 




Mediiine 


(\(n si. 
All of forearm, arm. 


Slight. 


Slight. 


Strength. 


14-60. 


An excellent exer- 


ball. 


shoulders, back. 






and 




cise for developing 




abdomen, a n d 


- 




accuracy. 




all muscles above 




chest. 








the pelvis. 


Parallel 


All of forearm, arm. 


Great. 


Moderate. 


Strength, 


16-30. 


Influence on co- 


bars. 


shoulders, pecto- 
rals, abdomen, and 
latissimus dorsi. 






balance, 

accuracy, 

and rhythm. 




ordination depends 
greatly on the in- 
tricacy of the exer- 
cises practised. 


Spring- 


Ail of thighs, legs. 


Gre.it. 


Moderate. 


Agility and 


12-30. 




boards. 


'and lower back. 






accuracy. 






Trapeze. 


Flexors of hand, 
wrist, forearm, and 


Extreme. 


Moderate. 


Balance, 

strength, 

and 


12-30. 


One set of exercises 
are for equilil)rium 




arm; all of .shoul- 








only; another are 




ders, the abdom- 






accuracy. 




like the typical hori- 




inals, and latis- 










zontal bar exer- 




simus dorsi. 










cises in their effect. 


Tumbling. 


The whole mu.scu- 
lar system, espe- 
cially legs, back, 
and neck. 


Extreme. 


Great. 


Rhythm, 

agility, 

strength, 

balance, and 

accuracy. 


14-30. 


One of the best all- 
around exercises. 



130 EXERCISE IN EDUCATION AND MEDICINE 

Here, again, it must be borne in mind that, in addition to the 
circles on the horizontal bar, the swinging exercises on the flying 
rings, vaults on the horse, and balancing exercises on the parallel 
bars, the same exercise may be interchangeable from one piece 
to another. 

For the healthy boy or girl of eighteen or thereabouts the best 
development would be obtained by a judicious mixture of gymnastic 
and athletic exercise in the open air. 

A course should be designed so as to employ all the activities 
of the muscular system — strength, accuracy, speed, agility, and 
endurance — as naturally as possible. 

A period of gymnastic exercise should begin with a ten-minute 
drill, including movements for both arms and legs, with special 
emphasis on correct carriage of the body and on deep breathing. 
This should be followed by exercises in rope climbing, on the 
parallel bars, horizontal bar, or flying rings, in which the arms are 
used; following this, exercises of agility, like vaulting over bars or 
the German horse, and simple ground tumbling. Each lesson 
should conclude with running or with a gymnastic running game of 
sufiScient speed to test the endurance. The period should occupy 
one-half to three-quarters of an hour, and should be repeated at 
least three times a week. If alternated with walks or out-of-door 
games, the maximum development and general education of the 
physical powers should be obtained. The mental exhilaration aris- 
ing from the emulation and competition that is found in a large 
class is an influence by no means to be neglected, especially in the 
young, although exercise will have- its effect whether this be pres- 
ent or not, just as surely as iron or castor oil. 

For those of mature age and a sedentary life, exercise should 
be directed principally to the muscles of the arms and trunk, care 
being taken not to overtax the circulation. Such exercises as 
throwing the medicine ball, — a large ball weighing from seven to 
twelve pounds, — hand-ball, and other ball games, combined with 
simple apparatus work, are usually effective and interesting. If 
combined with the fresh air obtained in a game like golf, tennis, 
or a brisk walk in the country once or twice a week, the result 



AGE, SEX, AND OCCUPATION I3I 

would be increased efficiency in business and a general feeling of 
well-being. For those of advancing years the necessity for exercise 
becomes less urgent, and the individual usually develops some 
plan to suit his own case. 

In a lecture given at the age of eighty-three Sir Hermann Weber 
spoke as follows on his method of using exercise for the prolonga- 
tion of life: 

"I have mostly commenced," he said, ''with moderately deep 
inspirations and expirations, continued during three to five minutes, 
once or twice a day, and have gradually increased the exercises to 
ten minutes or a quarter of an hour. The depth of each inspira- 
tion and expiration and the duration of holding the breath are 
likewise to be only gradually increased. At the beginning, a 
quarter of a minute for every inspiration or expiration ought to be 
sufficient. If this is well borne, each act may be gradually pro- 
longed in duration, so that in the majority of cases each inspiration 
and each expiration may be brought up to a minute. All the 
movements are to be made slowly, not rapidly. I usually advise 
to inspire in an upright position, with raised arms and closed 
mouth; to bend clown the body during the expiration, so that the 
fingers touch the ground or the toes. By degrees one can do 
several up and down movements during every inspiration, and bend 
and raise the body several times during the expiration. By this 
alternate bending and raising of the body we can gently strengthen 
the lumbar muscles, and, through this, successfully combat the 
tendency to lumbago. 

"Another useful combination with the respiratory exercises 
is the turning of the body around the axis of the spinal column 
alternately, with deep inspirations, from left to right, and with 
expirations, from right to left, the arms being half raised. By 
this movement we bring into action some of the muscles of the 
spine which are apt to be only imperfectly used by most persons 
in advanced years, and the stiffness of the neck and spine, and the 
tendency to stooping, so common in old persons, can be to some 
degree corrected by this kind of movement. If commenced in 
good time and practised regularly and thoroughly, swinging the 



132 EXERCISE IN EDUCATION AND MEDICINE 

arms around the shoulder-joint is likewise useful, and other 
combinations with muscle and joint movements will occur, but 
they should have accustomed themselves to these respiratory 
movements. The latter ought always to have our principal atten- 
tion, since to them the beneficial effect on the heart and lungs is 
mainly due. In addition to the influence on the circulation, the 
respiratory movements keep up the nutrition and efficiency of 
the lungs, which undergo in old age a kind of atrophy. The walls 
of the smallest divisions and air-cells become thinner, and a kind 
of senile emphysema is developed, which, by this exercise, is to 
some degree prevented. 

"Another important influence consists in maintaining the 
elasticity of the chest-walls, which are apt to become stiff in old 
age, and thus to interfere with free movements of the lungs and the 
pleura. If, for some reason, the erect position should be incon- 
venient, respiratory movements can be made also in the horizontal 
and sitting positions." 

In addition to these exercises, taken regularly every morning, 
he strongly advises a walk lasting from a half to three hours, part 
to be taken in the morning and part later in the day, and once a 
week he recommends a day of more prolonged exercise, and a 
holiday once or twice a year spent in a walking or climbing tour 
of three or four weeks. 

Occupation should have equal weight with age in choosing 
exercise. In the natural occupations of man, like farming, fishing, 
and lumbering, a great deal of muscular exertion in the open air is 
required, and the need for it is thus naturally provided for. 
During the last hundred years, however, the proportion of city 
dwellers has risen from 2 to nearly 60 per cent., and the artificial 
and confining conditions of a crowded city life must be faced. 
The segregation of masses of people limits the amount of space 
and air for each, and the necessity of further economizing 
energy by the use of machinery reduces muscular activity to a 
minimum. This applies especially to the most ''civilized" part 
of a civilized community, so that there has arisen a whole 
series of defects and diseases due to this suppression of the 



AGE, SEX, AND OCCUPATION I33 

natural muscular activity, or to its concentration on a few move- 
ments. 

School-children are taken for five hours a day from their 
natural occupation of outdoor play and confined more or less 
strictly to a sitting or standing position, making their bodies fertile 
soil for the growth and development of postural defects. It is 
necessary, then, that exercise in the open air for city children of 
the school age should be obtained, by playgrounds, situated in 
the more congested districts. 

The construction of roof-gardens, recreation piers, and other 
open-air breathing spaces is also directed by this same need, and 
the gymnastic exercises for school-children described in detail in a 
subsecjuent chapter are designed primarily for correcting the 
physical deterioration inevitably associated with confined school 
life. 

The difference between the physical life of a factory employee 
who tends a machine, and of a man whose active life is spent on 
the farm or in a lumber camp, is at once apparent, but even 
among business men the effect of underexercise and overeating 
is familiar to the physician, whom he consults for his constipation, 
biliousness, and headache, while the increase in nervous disorders 
in both men and women of a highly civilized community shows the 
disastrous effects of city life on the overstimulated nervous system. 
Among the influences that help to produce these conditions are 
the ease of intercommunication by mail, telephone, and telegraph. 
By these means alone a man may double or treble the amount of 
business done before their use, but at an added nervous expendi- 
ture. The constant harrowing of the emotions by the press, 
with its daily tale of horror, is a morbid addition to his load. 

Those who \We the confined indoor life of the office or study, 
overtaxing the brain and slighting the muscular system, would 
derive benefit from any exercise sufficiently vigorous to stimulate 
the circulation and the skin. It is to such men that the corres- 
pondence schools described in the previous chapter are most 
alluring, with their promises of incredible results from the modest 
expenditure of a few moments daily, while the secrecy with which 



134 



EXERCISE IN EDUCATION AND MEDICINE 



they are shrouded and the high price demanded for instructions 
add not a httle to their allurement. 

The design of a short course of exercises without apparatus 
for the average business man of mature age and sound constitu- 
tion has been undertaken by Dr. Luther Gulick, in his "Ten 
Minutes' Exercise for the Busy Man," and by J. P. MuUer, of 
Klampenborg, Denmark, in his "Fifteen Minutes' Work a Day 
for Health's Sake," where the first eight movements terminate 
in a bath and are followed by ten exercises in self-massage, and 
the following list has been compiled and found of proved value 
by the author, for those to whom the more interesting and 
varied but time-consuming exercises and games are prohibited 
by circumstances. These exercises may be done in the morning on 
rising or late in the afternoon, before dinner, and should occupy 
about fifteen minutes. 

They aim to stretch the thorax and expand the lungs, to give 
the heart some vigorous work, and to agitate and massage the 
abdominal organs, but one should begin gradually, take long 
rests, and use few movements at first. 

Exercise i. — Position: Standing; 
arms at sides, chin to neck, abdo- 
men in, and chest carried well for- 
ward without contracting the shoulder 
muscles. 

Movement: Arms forward raise, 
palms down, upward stretch, rise on 
tip-toe (Fig. 87), inhale. Sideways 
lower, palms back, keeping arms 
straight, slowly exhale and lower 
heels. Repeat twenty times. 

Exercise 2. — Position: Standing, 
arms behind back, hands resting in 
small of back, fingers interlocked, 
with palms facing backward (Fig. 88). 
Movements: Straighten arms, turning palms in, then down 
and then out, keeping fingers interlocked, Roll shoulders and 




Fig. 87. 



Fig. 88. 



AGE, SEX, AND OCCUPATION 



135 



arms into supination; extend neck (Fig. 89). Hold this position 
for a moment and then reverse slowly back to starting position. 
Note. — When the fingers cannot be kept in this position, start 
by holding a loop of cord in the hands 
instead of interlocking the fingers. Re- 
peat twenty times. 





Fig. 89. 



Fig. 90. 



Exercise 3. — Position: Lying on back, hands on hips. 

Movements: Raise each thigh alternately with bent knee till 
it touches the abdomen. Clasp hands around leg, and press in on 
the abdomen (Fig. 90) . Relax. Repeat tzventy times. 

Exercise 4. — Position: Stand- 
ing, hands behind head. 

Movements: Bend sidew^ays 
to right, then forward, then to 
left (Fig. 91), and then back- 
ward, circling five times each 
way. Keep feet together and 
the knees straight. Get far 
down on each side. Repeat 
twenty times. 

Exercise^. — Position: Stand- 
ing, hands clasped behind head 
(Fig. 92). 

Movement : Force the head and elbows back strongly. Relax, 
letting the elbows come forward. Repeat twenty times. 

Exercise 6. — Legs thirty inches apart, arms at sides. 

Movement: Raise arms above head, bend forward and toucli 




Fig. 91. 




136 



EXERCISE IN EDUCATION AND MEDICINE 



floor with both hands (Fig. 93). Rise slowly and bring hands 
to position. Repeat twenty times. 

Exercise 7. — Position: Arms forward (Fig. 94), then out and 
then up, stationary run. 





Fig. 93- 



Fig. 94. — Stationary running. 



Fig- 95- 



in five seconds. 



Movement: At the rate of fifteen steps 
Take fifty steps for each position of the arms. 

Exercise 8. — Position : Standing, hands clasped across abdomen. 
Movement: Inhale, pressing in abdominal wall (Fig. 95). 
Exhale, relaxing abdomen. Repeat twenty times. 

Exercise 9. — Position: Sitting on stool or on side of bed,, 
hands clasped behind the back. 

Movement: Trunk rolling, forward to right; backward and 
then to left (Fig. 96) ; then up to start- 
ing position. Repeat twenty times. 

Exercise 10. — Position: 
Standing. 

Movement : Arms side- 
ways, raise, upward stretch, 
inhale. Forward bend (Fig. 
97) and rise. iVrms side- 
Fig. 96. ways lower. Exhale. Fig. 97. 
To Finish. — Wring out a Turkish towel in cold water. Take 
it by both ends and rub hard back, chest, abdomen, and thighs. 





CHAPTER IX 
PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 

The segregation of city life, with its attending evils, weighs 
most heavily on the children of all but the very rich, and the 
survival of a strong and healthy race depends on providing breath- 
ing spaces and free play for them. 

Most cities have grown up without having borne this in mind, 
and city councils are now confronted with the need for buying and 
equipping playgrounds in the densely populated wards, where 
land is most difficult to obtain. 

In some cases ground is not to be bought, but, as Joseph Lee 
puts it, "There is just as much of the earth's surface as there 
was before, only it is a little higher up, " and the roofs have become 
a ground for play. 

In New York, according to the statistics of 1900, about 2700 
persons lived on one city block, in about 1500 rooms, 400 of which 
had no windows and no outside doors. The committee on play- 
ground organization made a map of the city, showmg the parks 
and playgrounds by green squares. Then they called in police 
captains from different districts, and asked them to point out the 
parts where restless boys gave the most trouble. In every case 
they put their fingers on the spot where there were no playgrounds, 
parks, or trees. The committee then put a red sign on each of 
these troublesome places. Other policemen, who said that the 
boys gave them no trouble, pointed to their districts, which were 
always close to the parks. The committee next stuck pins in the 
map to show where the schools were and where the children were 
thickest. This map was sent to the Mayor, and with it a copy of 
the State law, which reads: "Hereafter no school-houses shall 
be constructed in the city of New York without playgrounds to 
be used with the same." 

137 



138 



EXERCISE IN EDUCATION AND MEDICINE 



Wherever the pins were thickest on the map, showing the 
most children, the red signs were thickest too, and it has since been 
proved that the putting of green spots into these regions will drive 

the red spots out. 

This was a graphic 
method of showing the in- 
fluence of play on juvenile 
crime, so much of which is 
due to lack of a proper out- 
let for the natural impulses 
and instincts of the healthy 
child. 

So long as the surround- 
ings are normal for the best 
development of a child's 
neuromuscular system, the 
choice of play and its con- 
duct may be left to the 
natural instincts of the child, 
but in a city these normal 
instincts are thwarted, and 
if exercised at all, his games 
of ball or tag, his hunting 
and fighting games, bring 
him into conflict with the 
police, and land him in the 
juvenile court, accused of 
such crimes as destruction 
of property, disorderly con- 
duct, and burglary. 

One of the strongest 

pleas for the establishment 

of playgrounds is made from 

this social side rather than 

from that of physical education proper. It was proved that 

juvenile crime decreased over 60 per cent, in each district 




Fig. 98. — City conditions showing need of 
playgrounds (Playgrounds Association of Phil- 
adelphia). 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS I39 




Fig. 99. — A typical east side street in New York city. 

where the right to play and a place to play was given to the 
children. 




Fig. 100. — .\n improvised shower-bath (Playgrounds .'\ssociation of Philadelphia). 



140 



EXERCISE IN EDUCATION AND MEDICINE 



In the poor and crowded districts of the city the condition of 
the homes is such as to make free play impossible; the children 
have not even room or opportunity to run or bathe, and the city 
must provide them with both. 

The necessity of teaching the language and the ideals of their 
adopted country to the hordes of foreigners who yearly immigrate 
to such cities as Chicago or New York make the playgrounds and 




Fig. loi. — A hurdle race under difficulties. 

municipal gymnasiums a most valuable means of education, and 
the experience of Chicago among the Bohemians, Lithuanians, 
and Poles has been such as thoroughly to justify the large annual 
expenditure. 

The introduction of playgrounds in American cities has 
usually been the voluntary labor of private committees, cooperating 
with the school boards, obtaining the use of certain school yards 
and open spaces by donation or purchase, equipping them, and 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



141 



demonstrating their usefulness to the city, and so bringing on the 
council the influence of the people directly benefited, and finally 




securing purchase of the ground and i)crmancnt supcr\ision l^y 
the municipality. 

Playgrounds should be of three distinct types — small, medium, 
and larsre. 



142 



EXERCISE IN EDUCATION AND MEDICINE 



Type I. — Numerous small pieces of ground are usually obtain- 
able by utilizing vacant lots. These can be transformed into 
playgrounds for small children of both sexes, and should be 
equipped with a few small swings, see-saws, a sand pile under a 
canvas awning, toilet facilities, and a shelter for rainy weather. 
If possible, a shallow wading pool with sand or concrete bottom 
should be provided. 

The expense of such an equipment need not exceed fifty 
dollars, distributed somewhat as follows: 

1 . Ten-foot double swing frame 
with triangular ends, braced, and 
two swings- — ten to twenty-five 
dollars. 

2. Children's six-foot swings, 
with canvas scups for little chil- 
dren to swing or sleep in, well 
protected from the sun — ten to 
thirty-five dollars. (See Fig. 103.) 

3. Two or three see-saws with 
14-foot boards, at five to ten 
dollars each. 

4. Sand-box, varying in size 
and shape according to the space, 
filled by one or two loads of fine 
white sand^five to fourteen dollars. 

5. Awning for protection against 
the midday sun and shelter for 
rainy weather — ten to sixty dollars. 

There should also be connec- 
tion with the water-supply of the 




Fig. 103. — Construction of a swing for 
little children in the playground. 



city. 



Much of the equipment is frequently obtained from interested 
supporters of the movement. 

The back yard may be turned into a playground of this kind, 
as has been done in Philadelphia by Dr. Talcott Williams and. 
others. The arrangement of apparatus would be as in Fig. 104. 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



143 



Individuality will naturally be shown in the equipment of 
these small playgrounds, but they should be scattered about at 



}.^w■ ^ > ' .^^^^^^^^^^^^.^^^^^^^V^'>^^^^.^^^■^^^^^v^^'JL^'>^^^^.^.^^ 



»TJ S^s^s\^^^l^^^s^s^^^■■s^v^^^^^■.\^^^^^\^^^^^^^^^^^v^^^^^^^^ 



© 




0&m 






distances of not more than three or four blocks from the homes 
of the children who have to use them. Small children cannot 
go more than a few hundred yards to their playgrounds, and for 



144 



EXERCISE IN EDUCATION AND MEDICINE 



that reason the city parks are unavailable except on a holiday or 
other great occasion. 

Type II. — The second type of playground should consist of a 
piece of ground, from two to ten acres, with a more substantial 
shelter, containing toilet-rooms, shower-baths, and an ofhce for the 
supervisor. The ground itself should be provided with a wad- 
ing pool, a sand pile, or court for young children, and a swim- 
ming pool for those who are older. 



SCHOOL PLAVCHOUND 




Fig. 105. — Type I of playground (Elizabeth Rafter). 



The sand pile here may be extended to the dignity of a garden 
or court, fenced in, and provided with simple toys, buckets, shovels, 
and building blocks. These are frequently carried off, but this 
was prevented in one playground by an effective checking system. 
The child wanting a pail or shovel deposited his hat, which was 
returned when he returned the tools. The sand should be exposed 
to the sun and rain, and great care should be exercised to prevent 
the spread of communicable diseases through this medium. 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



145 




Fig. 106. — A wading pool in Fairmount Park. 

The center of the field should be supplied with fixed apparatus 
(Fip;. 108). This consists of a framework of iron upon which are 




Fig. 107. — Sand pile (Watervievv Park, Gcrniantowii, Pa.). 

suspended ladders, rings, and ropes, as well as permanent sets of 
parallel bars and horses of varying heights, jump stands, giant 
strides, merry-go-rounds, circle bars, and slides. Where the ground 



146 



EXERCISE IN EDUCATION AND MEDICINE 





Fig. 108. — An up-to-date playground equipment for second type of playground. 

is large enough, there should be a running track surrounding the 
field. These playgrounds are necessarily fewer in number than 




Fig. 109. — Apparatus in use (Gymnasium, Washington Park, Pittsburgh). 

the first, but should not be more than half a mile apart in the 
crowded sections of the city. They are intended for boys and 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



147 



girls from twelve to eighteen years of age, with special quarters 
for younger children.^ 




Fig. no. — Starr Garden, Philadelphia, Type II of playground. An ideal pla_v- 
ground e.xcept for the absence of a swimming pool (Playgrounds .Association of Phila- 
delphia). 

^ The school yard may be turned into an ideal playground of this type, be- 
cause the schools are placed where the children are thickest. They belong to the 



148 



EXERCISE IN EDUCATION AND MEDICINE 



Type III. — The third type of playground should be found in 
the outskirts of the city, usually connected with the park system. 
These playing fields, like Boston Common or Belmont Plateau in 
Philadelphia, should be of such size as to allow of two baseball 



MlwrriPAi. p.APK- pi. AYoRo'iirip 




Fig. III. — Large municipal playground plan (Elizabeth Rafter). 

diamonds or foot-ball fields, a quarter-mile running track, the out- 
door apparatus described in the second type, and a large gym- 
nasium hall and dressing rooms. 

municipality and have the necessary conveniences already installed, with the 
possibility of using the basement in rainy weather. The yards are already 
enclosed and the janitors can look after the apparatus when the ground is not 
in use bv the children, thus preventing the wanton destruction of property 
that is so frequent. The field apparatus can also be used all year and not in 
the summer only, and the cost of administration is thus greatly lessened. 

If the school yards are used, boards of education are encouraged to buy neigh- 
boring property to enlarge them, as has already been done in Philadelphia and 
elsewhere, and both municipality and school board profit from the combination. 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



149 




150 EXERCISE IN EDUCATION AND MEDICINE 

In the building there should be shower baths, and close by a 
swimming pool with deep and shallow divisions, and also a wading 
pool for the small children and girls. In some cities, notably in 
Chicago, this type of playground has been made a social center, 
the permanent building containing a large auditorium for lectures 
and various social gatherings of the people of the quarter. Every 
attempt is made to encourage these gatherings, as well as the 
specific physical training for which these playgrounds were origin- 
ally designed. 

Play in itself is essentially neither good nor bad, but it has 
great possibilities for good in the hands of a capable director, 
and the profession of playground supervisor is a distinct specialty 
in physical education, requiring unusual natural gifts and careful 
preparation. 

The supervisor of the smaller playgrounds for young children 
should be familiar with kindergarten methods: .she should teach 
them the simple kindergarten games and direct them in their 
play in the sand heap, having story-telling hours and other occupa- 
tions most interesting to children of that age. This may well be 
combined with visiting the children's homes and tactfully instilling 
in the parent's minds the importance of cleanliness and personal 
hygiene. 

The larger playgrounds require a man to give at regular hours 
a definite amount of gymnastic exercise in the form of marches, 
setting-up drills, and apparatus work. He should organize gym- 
nastic and athletic games, of which there are many specially 
designed to be played by a large number of players in a small 
space. DeGroot's playground ball is popular with the boys of 
Chicago, and ideally suited for these conditions. He should also 
organize among the boys athletic contests and games extending to 
interplayground contests, in which loyalty to their section or even 
to their city is taught, and the spirit of fair play and clean sport 
is instilled in their youthful minds. 

A period of exercise should begin with marching, light setting-up 
movements, and then exercises on the fixed apparatus, in which 
the possibilities of each piece are shown. As a rule, less emphasis 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



151 



is laid on the form in which a feat is accomplished than indoors. 
The apparatus is considered much more casually. 

This should be followed by an athletic game or contest, like 
the Avheelbarrow race, run by two boys, one grasping the ankles 




of his companion, who runs forward on his hands; the three- 
legged race; obstacle races; relays; jumping and vaulting, and one 
of the many games with the basket-ljall or medicine ball. 



152 EXERCISE IN EDUCATION AND MEDICINE 

The wading pool can be systematically used for games of tag, 
leap-frog, tub-racing, and the like, the children, of course, being 
suitably dressed or, rather, undressed. Of these sports children 
never tire and the spectators are entertained not a little. 

Many children learn to swim instinctively or are taught by 
companions, but the teaching of swimming should be part of the 
playground activity, and games of water polo and water basket-ball, 
as designed by Dr. A. E. Garland, of Boston, are much in vogue. 

Certain days should be set apart for girls if they cannot have 
their own pool, but the playground instruction for them would 
differ in certain important particulars from the course most suitable 
for boys. 

The round games are always popular with them, especially 
singing and marching, the salute to the flag, and, above all, dancing. 

Most of the European races are rich in folk-dancing, and the 
exhibitions of these dances of Scotland, Sweden, Russia, Spain, 
and Bohemia at the playground congresses have always attracted 
deep interest. From such sources American folk-dancing is being 
evolved. The contra danses of America, English in origin, are 
widely used as quadrilles, and the Sir Roger de Coverly, or Virginia 
reel, with modern embellishments, is always popular. Dancing 
has almost entirely replaced athletic contests in the girl's branch 
of the Public School Athletic League of New York, with the 
greatest advantage. 

Here, again, is shown the necessity for special training of 
teachers who are to take up this profession of playground super- 
visor. 

Where playgrounds cannot be otherwise obtained, the school 
playgrounds are used with great advantage, both for the first and 
second grades, as already described, and the regular school-teachers 
are frequently employed as supervisors after a course of training 
to fit them for this specialty. 

The need for playgrounds and breathing spaces in the crowded 
wards of the great cities jumps to the eye, but it also exists in the 
country village, the town, and in those parts of a city where poverty 
is unknown. While the usual attack on the problem is made by 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 



153 



the establishment of playgrounds first, and gymnasiums and baths 
afterward, the provision of systematic exercise for city residents 
has been approached in the reverse way, in at least one city, where 
the slum is non-existant and the community is prosperous and 
wealthy. 

The city of Brookline, Massachusetts, began the campaign 
for good health and sanitation by building a municipal bath-house 
equipped with showers, dressing-rooms, and a large swimming 




Fir. 1 14. — The main exercise hall of the Brookline municipal j;yinnasiuni and baths. 

]jool. Free instruction in swimming was given to residents of the 
town in the large pool, and in a smaller pool constructed for the 
purpose of accommodating the younger children. 

Closely following this bath-house a large gymnasium was 
built by the municipality, and put under the control of a com- 
mittee of citizens who are held responsiljle for its management, tl:c 
appropriation for its maintenance being granted by the city council. 

The gymnasium building contains two exercise halls, one, 
100 feet in length by 71 feet in width, with a ridge roof, lighted by 



154 



EXERCISE IN EDUCATION AND MEDICINE 



windows and skylight, making a height of forty-five feet in the 
center. 

This hall is equipped with a complete outfit of gymnastic 
apparatus, and contains a running track, also used as a gallery for 
spectators at the exhibitions. The climbing and fixed apparatus 
are in sets of four, arranged so that the floor may be rapidly cleared. 

A small gymnasium, 74 feet by 34 feet, having a height of 
22 feet, is equipped with Swedish apparatus, and is used for the 
overfloAA' from the cliildren's classes. 




f the Tirooklinc niunicipal gymnasium and baths. 



There are special rooms on the fourth floor and in the basement 
for private instruction and for games and corrective apparatus. 

All the regular classes in the gymnasium are free to residents 
of Brookline and non-residents are admitted on the payment of a 
fee. Preliminary medical examination, while not obligatory, is 
strongly recommended. 

The schedule of classes in the annual report of Mr. J. Leonard 
Mason, the director, shows the scope and variety of a week's work: 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 1 55 

Monday. 

Women's afternoon class 3: 45 

Men's afternoon class 5- 15 

Men's evening class 8: 00 

Tuesday. 

Women's morning class 10: 30 

Girls under fourteen \'ears, afternoon class 2: 45 

Girls over fourteen years, afternoon class 3-45 

Men's afternoon class 5-i5 

Women's evening class 8: 00 

Wednesday. 

Public school teachers' class 3'°° 

Boys under fourteen years, afternoon class 2: 30 

Boys over fourteen years, afternoon class 3^ 45 

Young men's evening class 8: 00 

Thursd.w. 

Women's morning class 10: 30 

Women's afternoon class 3-45 

Men's afternoon class 5- i5 

Men's evening class 8: 00 

Frid.w. 

Girls under fourteen years, afternoon class 2: 45 

Girls over fourteen years, afternoon class 3-45 

Women's evening class 8: 00 

S.a.txjrd.\y. 

Corrective gymnastics 9 • 3° 

Children under ten years class 10: 30 

Boys under fourteen years class 2 : 30 

Boys over fourteen years class. 4: 15 

Young men's evening class 8: 00 

Children from six to ten are given marching, plays, and games, 
to music, under a woman instructor, and are trained in the simplest 
free exercises, using the larger muscle groups. Boys of fourteen 
have more complicated drills, with much exercise in tumbling, 
climbing, and gymnastic games, but little of the heavy work char- 
acteristic of the German gymnastics. For girls of the same age 
dancing steps to the music of a piano are extensively employed. 
Girls from fourteen to sixteen are taken as a separate class. 
Though they have passed the doll stage and are not interested in 
the childish plays, they have not yet learned to care for the rugged 
games used by older girls. 



156 EXERCISE IN EDUCATION AND MEDICINE 

This age division has not been found necessary among the 
boys, according to Mr. Mason. 

Women from twenty-five to sixty have their classes in the morn- 
ing, and begin their lesson with marching, setting-up movements, 
and the light, graceful calisthenics requiring skill; women of this 
age are fond of balancing movements and of dancing, the slower 
rhythmic movements and relaxing exercises being used with great 
advantage. Violent exercises of jumping and vaulting, in which 
the body may be jarred, are avoided. The women's classes are 
very popular, and have a distinct social value, which their members 
heartily appreciate. The afternoon class for women is attended 
by many school-teachers who are mentally tired from their day's 
teaching. For them the exercises are rhythmic and given by 
imitation, all exercises requiring close attention by word of com- 
mand are avoided. 

The working-girls and women come in the evening, and 
require more strenuous work. They are fond of the apparatus 
and social dancing with music. 

In addition to what may be called the routine work of the 
gymnasium, an opportunity is given for the practice of swimming, 
wrestling, fencing, and gymnastics, and clubs for their promotion 
are organized. 

The senior boys take up the heavier apparatus work and indoor 
athletics, while the girls are instructed in athletics, modified and 
reduced, some little apparatus work, and dancing. The strenuous 
competitive games like basket-ball are not encouraged, although 
they are permitted. 

Business and professional men, varying in age from thirty to 
sixty years, do not tolerate work in which close continual attention 
is required. Music is thus of special value to accompany the 
setting-up exercise with which their class begins, and simple 
rhythmJc dancing steps to music are very popular with them. 
The movements of boxing and games, like indoor baseball, also 
appeal to them strongly, and a favorite exercise is found in the 
medicine ball games, which invigorate the muscles of the arm and 
trunk overstrained or unused by many business and working men. 



PLAYGROUNDS AND MUNICIPAL GYMNASIUMS 1 57 

In a town like Brookline, of less than 30,000 people, the average 
weekly attendance at the gymnasium during the first year was 
1473, of which over 800 were girls and women. 

An outgrowth of the movement for play has been the establish- 
ment of summer camps for city children, frequently started by 
private benefactors, newspapers, or charitable organizations. In 
them provision is made for physical training, and the days are 
spent in roaming the woods and hills or on the water. Large 
numbers of poor children are thus given the advantage of country 




Fig. 116. — Morning gymnastics at camp Tecumseh (Dr. Orton's camp). 

air and surroundings in the hot weather that is so fatal to the chil- 
dren of the city. 

The Young Men's Christian Associations have been par- 
ticularly active in providing camps for their members, where they 
may live under canvas for July and August, and private camps 
have been established by Dr. George W. Orton, Dr. George L. 
^Meylan, and others in the mountains of Maine, New Hamp- 
shire, and elsewhere. 

In 1907 more than 25,000 boys were spending their holidays 
in this way. 

In addition to this over 5000 boys who were unable to afford 
the moderate expense were housed in the settlement camps. 

The first girls' camp was started in 1903, arifl four years later 
there were at least thirty such camps in operation. 



CHAPTER X 
PHYSICAL EDUCATION IN SCHOOLS 

More than 23 per cent, of the total population of America 
spends from three to five hours a day in school, and with the 
extension of the public-school system the responsibility of educa- 
tional boards increases correspondingly toward the growing 
number of children under their care. 

The normal life of a child during its waking hours is one of 
muscular activity, but if discipline is to be maintained in the 
school-room., the teacher must inevitably suppress a greater part 
of this restlessness so fundamentally related to gi-owth. 

The lessening of natural movements by school limitations 
during the years of growth is harmful not only because muscular 
exercise is decreased, but because nervous tension and strain 
are more than correspondingly increased. This tension should be 
repeatedly relaxed by periods of physical exercise designed with 
three objects in mind — first, to correct the physical faults and de- 
formities fostered by the sitting posture; second, to recreate the 
mind and body of the child, and, third, to develop his physique 
along natural and normal lines. 

In the building of schools the sanitary engineer should see that 
every school-room has 15 square feet of floor space and 300 cubic 
feet of air for each pupil, and a system of ventilation capable of 
supplying him with 30 cubic feet of pure air every minute. It is 
his duty to see that the light is abundant, the window area about 
one-fifth of the floor space, and arranged to Come from behind or 
over the left shoulder, and not reflected directly from, the paper 
on the desk into the eyes; that the desks are designed to fit not 
only the child of normal size for his grade, but also those who 
are abnormally large or small. C. L. Scudder, in his investi- 
15S 



PHYSICAL EDUCATION IN SCHOOLS 



159 



gation of school-seating, in Boston, found girls differing seven 
years in age and nearly twenty-two inches in height sitting at desks 
and seats of exactly the same size, and discovered gross misfitting 
of the desks in nearly every room he examined. In most schools 
there are still found seats so high that the pupil cannot touch the 
floor with his heels, desks of such height that the book is forced 
close to the eyes and myopia encouraged. Again, there are found 
desks so low that the round shoulders, the drooping heads, and 
the flat chests of their occupants are sadly noticeable. 




117.— The Garber desk, adjustable by the puiiil. 



The relation of the seat height to the desk height should be 
such as to permit the elbows to rest on the desk without stooping 
forward or unduly raising the shoulders, and the desk edge should 
overlap the front edge of the seat. In a carefully appointed school- 
room at least one row of seats and desks should be made adjustable 
in order to fit pupils that are not of the regular grade size. By 
this is avoided the unsuccessful and burdensome method of having 
all the school furniture made adjustable, which adds an additional 
weight to the teacher's alreadv overloaded shoulders and is <i;en- 



i6o 



EXERCISE IN EDUCATION AND MEDICINE 



erally neglected. Most of the difficulty in seating pupils can be 
overcome by a self-adjusting desk and foot-rest like that invented 
by J. P. Garber, of Philadelphia, which can be changed to fit by 
the pupil himself with little noise or loss of time, the two great 
objections to adjustable furniture (Figs. 117, 118). 

A perfect fitting seat and desk can guarantee only that the 
child shall be in the correct sitting position occasionally throughout 
the school day, for, however well the desks may fit, pupils rapidly 
slump unless study periods are repeatedly interrupted by oppor- 
tunities for movement and exercise. The upper part of the body 




Fig. iiS. — Showing mechanism for adjustment of the Garber desk: lo, Adjust- 
able top; 14, pivot of attachment for adjustable portion of top; 19, lever pressed up by 
fingers to overcome the spring 21 and release the rod 20 from the serrations 9, allowing 
the desk to be raised or lowered at will. 



leans forward upon or against the desk, constricting the chest, 
crowding the abdominal organs, and impeding the venous circula- 
tion. The weight is supported by the arms, and the head, neck, 
and spine hang by the muscles of the shoulder-blades in abnormal 
curves. To relieve this overstrain of the back and shoulder mus- 
cles the pupil changes to a pose resting the entire weight of the 
trunk on the shoulder-blades and lower end of the spine (Fig. 119). 
The back sags down in a single long curve, the chest contracts, 
the breathing is impeded, and the circulation made sluggish. 
This position stretches the muscles and ligaments of the spine, 
rounds the back and shoulders, and shoves forward the chin. 



PHYSICAL EDUCATION IN SCHOOLS l6l 

The correct sitting posture is one in which the pupil sits erect, 
the pelvis resting equally on the seat, with the arms beside the hips 
and the head poised so as to bring the center of gravity within a line 
joining the seat bones. This posture is economic in muscular 
energy, and most conducive to correct carriage, but the demands 
of school life do not permit the pupil to keep it long. Reading, 
writing, and drawing are exercises that require deviations from, 
the ideal, and if we add to these requirements ill-fitting desks 
and long periods of sitting in which bad posture becomes habitual, 
the mischievous result cannot lons^ be in doubt. 




Fig. 119. — Faulty posture (Shaw). 

The work of the school-day should be arranged with these 
things in mind. 

The first year of the child's school-life should not have more 
than one-third of the time in confinement at the desk (Shaw). 
Short periods of sitting, followed by double that time spent in 
muscular acti\'ity out of the seat, should be the rule. This actix'ity 
may in most cases consist of movements correlated with intellcclual 
exercise. In the kindergarten the exercise is admirably combined 
with mental culture by the teaching of imitative games in which the 
large muscle groups are exercised in hopping, jumping, and run- 



1 62 



EXERCISE IN EDUCATION AND MEDICINE 



ning, and in imitating with the arms the flight of birds and insects. 
The circulation is stimulated, and postural faults are prevented, 
while at the same time the child is taught valuable lessons in 
natural history, in which his interest never flags. The names of 
these games are suggestive of the action: "The windmill's fans 
around they go" (Blow). ''Mow, mow the oats" (Hofer). 




Fi^. 1 20. A kindergarten game in the school yard. 

"Little ball pass along" (Jenks and Walker). They may be 
divided into: 

1. Games of pursuit — "Chasing the squirrel." 

2. Imitation games — "Shall we show you how the farmer?" 
(Blow). 

3. Rhythmic and dancing games — "Tick tock'" (Hubbard). 

4. Marching games — "Left, left, listen to the music "(Gaynor). 

5. Ball games — "In my hand a ball I hold" (Jenks and 
Walker). 



PHYSICAL EDUCATION IN SCHOOLS 



163 



They are always accompanied by music, and most of them can. 
be carried on to the primary schools. 

In the succeeding years of the elementary school the proportion 
of time spent at the desk may be gradually lengthened, but short 
periods of respite from sitting should be frequent and devoted to 
brisk physical exercise. In the last year of the elementary school 
course there should be four stated periods of three minutes each 
during the morning and three during the afternoon session, 
devoted to exercise, corrective in character, and designed to bring 




Fig. 121. — A recess game at the Thompson Street School, Philadelphia. 

into use muscles inactive or overstrained at the desk. In addition 
to this there should be a recess in both morning and afternoon 
session of not less than fifteen minutes, so that the school-room 
may be thoroughly aired. All the pupils, if the weather and 
climate ]jermit, should go out-of-doors and engage in spontaneous 
[jlay, where they can run, shout, and give vent to their pent-up 
animal spirits, quicken their circulation, and relicx'e the ncr\-ous 
tension caused l^y keejjing still, and so rest and invigorate all their 
nervous and muscular system. In many cases, however, partic- 
ularly in America, children seem to have lost the knowledge of 



164 



EXERCISE IN EDUCATION AND MEDICINE 



games and play and have to be taught them. This is attributed 
by Guhck to the lack of play traditions found in the mixed and 
constantly shifting population of American cities, where two gener- 
ations of children seldom grow up in the same place to pass down 
their customs and play rules to their successors. 

Special games have been designed and collected by E. H. Arnold, 
of the Boston Normal School, and others, adapted from old and 
popular children's plays for the use of the many children who 
have to occupy the confined space of the playground. These 






Fig. 122. — Mosher's postures in standing. 

games should be taught and practised during the recess period, 
although it is not so much the number of games that is neces- 
sary, but the time and space to play a few good ones. 

The school-day of children in the higher grades should have 
two five-minute periods of exercise in addition to the purely 
corrective work of the three-minute periods, and the games of the 
recess above described. These exercises should be designed to 
promote quick, strong muscular control; to expand and enlarge 
the chest for deep breathing; to bring the blood out into the 
extremities; and to teach the proper carriage of the body. In 



PHYSICAL EDUCATION IN SCHOOLS 165 

teaching the correct standing posture, the teacher should be on the 
watch for the most frequent of all defects, that position where the 
weight is habitually borne on the right leg, the left being inactive 
and placed out to the side (Fig. 122, i). 

It is not possible for a child to remain long at rest with the 
weight equally on both feet (Fig. 122, 2), and since the tension on 
both legs is the same, the child rapidly tires. The best position 
to teach is that recommended by Dr. Mosher (Fig. 122, 3), in which 
one foot is placed slightly in advance of the other, changing the 
feet as the weight-bearing leg tires. 

The school-room has been the battle-ground on which the 
Germans and Swedes have fought the most vigorous campaign 
in favor of their respective systems. Both have a place in the 
day's work. The more purely corrective exercises, done to word 
of command and designed to prevent or remedy flat chest, round 
shoulders, and faulty standing positions, are founded more or 
less upon the Swedish system, while rhythmic exercises, done to 
music and the teaching of movements by imitation, are more 
characteristic of the Germans. Excellent systems of graded work, 
in the school-room, in which both these ideas are used, have been 
arranged for the public schools of New York, Philadelphia, and 
Cleveland. In Cleveland the day's order of the Swedish system 
is closely followed for the corrective exercises. A lesson begins 
with— 

1. Order movements, to enlist the attention: right and left 
face, etc. 

2. Movements to expand the chest; backward bendings or 
arch flexions. 

3. Breathing exercises. 

4. Balance movements for coordination, like toe-standing 
and walking. 

5. Back, including shoulder-blade, movements for the spine 
and general carriage of the body 

6 Abdominal movements for the abdominal muscles. 
7. Bending and twisting movements for the lateral muscles of 
trunk and spine. 



i66 



EXERCISE IN EDUCATION AND MEDICINE 



8. Breathing movements. 

9. Jumping movements, like the fall-outs, and springing move- 
ments, the most violent of the series, and repeated to the point of 
breathlessness. 




Fig. 123. 



-Method of using the school furniture to replace gymnastic apparatus in Phil- 
adelphia schools. The "dip" between the seats. 



10. Slow, deep respiratory movements, to calm the respiration 
and circulation and prepare for rest. 

Practically no apparatus is used, except the school seats and 
desks, and the alternate rows of pupils, who act as living supports 
in duplicate movements (Figs. 123 and 124). 




Fig. 124. — "Follow your leader" through the seats and aisles of the school-room. 
The alternate files in the picture should be reversed, and the game continues till the 
players are back to their own desk. 

In the Philadelphia schools recreation drills are used in addition 
to the more corrective Avork, and sometimes the children are 
allowed to run freely in the school yard for one minute, or to take 
jumping and vaulting exercises, with the desks as apparatus. 



PHYSICAL EDUCATION IN SCHOOLS 1 67 

Rhythmical exercises to music or gymnastic games are also em- 
ployed, but all gymnastic work in the school-room should always 
be short, light, and corrective in character, and must stop short 
of perspiration. 

Every school should be pro\'ided with a gymnasium large enough 
to allow vigorous ^^■ork for an entire class, or for several classes 
together. Here the dressing-rooms and lockers for each sex per- 
mit a complete change of clothing, with the liberal use of the 
shower-bath and swimming pool. The school gymnasium should 
be in a separate building, if possible, but when this is not feasible, 
the upper floor should be used in preference to the basement, 
because of the impurity of the ground air. The ventilation 
should be abundant, with forced draft, and the ceiling should 
be at least twenty feet high. A gallery containing a running 
track should surround the room, and vaulting bars, ladders, 
and suspended parallels may be attached beneath to it. The 
vaulting horses, jumping standards, parallel and horizontal bars 
should be in groups of from four to six, to facilitate the handling 
of large classes, and these should be set in the floor sockets, easily 
removable, so that the floor may be cleared for mass drills, marching 
exercises, and games. Around the walls, chest weights and other 
developing appliances should be set, with the bom and stall bars 
and the dumb-bells, clubs, bar-bells, and wands. There should be 
an abundant supply of mats. A schedule of hours should be 
made for the use of the room by boys' and girls' classes The 
equipment must vary widely with the conditions, and a reliable 
firm of gymnasium outfitters should always be consulted for the 
design and instalment of the apparatus. 

If there is a gymnasium, there need be little or no equijnnenl 
in the playground, which must provide 30 square feet of space for 
each pupil (Burnham), or a plot 300 feet by 100 feet for a school 
of 1000 pu{)ils; but if not, the apparatus should be like that of a 
playground of the first or second class, already described. 

For outdoor exercise the need of playgrounds about the school- 
buildings becomes more and more urgent; and in Philadelphia and 
New York the roof itself is used, caged in by wire netting. These 



1 68 



EXERCISE IN EDUCATION AND MEDICINE 



roof playgrounds give the only opportunity a child may have for 
engaging in outdoor athletics, and in New York city, where the 
population is so dense, it has made possible the formation of the 
public School Athletic League, which is now over half a million 
strong. 

The Public School Athletic League of the city of New York 
was founded in 1903 by Dr. Luther Halsey Gulick, then Superin- 
tendent of Physical Education. He brought to the attention of 
the Board of Education the deplorable physical condition of the 
children attending the public schools, most of them living in 
many-storied tenements, each with a population as great as a 




1* ig I.-, — \ root pLi} ground m a c row ciecl section at New \ ork (_Pla\grouniK \sso( lation 

of New York). 

small village, with no playgrounds but the crowded streets and 
congested sidewalks. It was estimated that in the tenement 
district of the east side, Manhattan, there w^as a child for each 
running twenty-four inches of the street, which was emphasized 
as just the space required for a grave. The committee of the 
board approved the scheme, and incorporated the league. The 
organization was perfected by the election, as officers, of men in- 
fluential in the political and financial world, and by securing the 
co5peration of teachers and principals. 

The first athletic meeting was held at Madison Square Garden 
before much opportunity had been given for work among the boys> 



PHYSICAL EDUCATION IN SCHOOLS 



169 



and brought out 1500 entries. Since then the league has given 
over 600 athletic meetings in one year, at many of which over 
1000 competitors took part; and now a single school may hold a 
meeting with 700 competitors, the games covering all kinds of 
athletic competition. Running and relay racing constitute a major- 
ity of the events, not only because of their value as exercise, but 
because they enable a large number of boys to be handled rapidly. 




Fig. 126. — Argument in favor cf weight classes — the small boy is the older by three 
months (Handbook Public School Athletic League, N. Y.). 

Boys were classified by weight instead of age, the scales being set 
at the weight limit, and the boy who raises the bar on the scales 
is ineligible. This is quick and conclusive, and prevents all possi- 
bility of discussion. There are also contests in high jumping, pole- 
vaulting, jjutting the shot, basket-ball, soccer fool-ball, cross- 
country running, swimming in the public baths, ice and roller 
skating, and shooting. Baseball is perhaps the most popular, 
and in 1907 there were 106 baseball teams competing against each 



lyo EXERCISE IN EDUCATION AND MEDICINE 

other in the league. Valuable trophies and medals have been 
secured for competition, and many other devices are used for 
extending the exercise to as many boys as possible. 

Prize buttons were given to all boys who achieved a certain 
standard of merit. To win the button he must chin the bar, run a 
certain distance, and jump a certain height, according to his age or 
weight. The standards have been set as follows: For elementary 
school boys under thirteen years, 6o-yard dash, 8f seconds; chinning 
the bar, 4 times; standing broad jump, 5 feet 9 inches. For all 
other elementary school boys: 60-yard dash indoors, 8 seconds; 
100-yard dash outdoors, 14 seconds; chinning the bar, 6 times; 
standing broad jump, 6 feet 6 inches. For high school boys: 
220-yard run, 28 seconds; chinning the bar, 9 times; running high 
jump, 4 feet 4 inches. This has been extended to class competition, 
where all boys in the class compete to make an average. 

The league aids in the maintenance of discipline by requiring a 
certificate from the principal stating that the boy had reached the 
passing mark in his studies and deportment, before allowing him 
to compete either for a button or other prize. 

In the first contest for the button only three or four out of a 
school of 500 could pass the test, but with practice 1162 boys 
qualified in 1904, and two years later this number had more than 
doubled. 

Teachers have been astonished, as well as pleased, with the 
improvement in discipline among these young and ambitious 
athletes, and this alone has insured their active cooperation, as 
well as the enthusiastic support of the boys. 

Systematic instruction in military rifle shooting has been made 
possible by the invention of the subtarget machine. It consists of 
a standard, with an ordinary Krag military rifle attached to a 
mechanism on top. This is so adjusted that when aim is taken 
with the rifle at a target across the room and the trigger pulled, 
the machine registers upon a miniature target the exact relative 
place that would have been hit if the gun were loaded. As there is 
no danger connected with it, the practice is rapid and economical, 
the mechanism being easily set up in any school-room. The 



PHYSICAL EDUCATION IN SCHOOLS 



171 



instructor standing at the boy's side is able to follow the man- 
ner in which he is aiming and to correct his defects. In- 
struction in the holding and sighting of the rifle is given, and 
annual interschool contests are held, ending in a final contest 
among the winning schools at Creedmoor, with the actual rifle, 
at distances of from 100 to 400 yards. The boys thus have an 




Fig. 127. — Subtarget gun machine for rifle practice in high schools (Handbook of 
Public School Athletic League, N. Y.). 



opportunity for acquiring the knowledge of wind, atmosphere, 
and light, necessary for good shooting in the lield. This has been 
made part of the program for the School Athletic League, and has 
been a source of keen interest to the lioys, many of whom have 
acquired great skill. Ujjon attaining a certain degree of cliiciency 
each competitor is given a badge. The national im])ortance of 
having an army of boys graduated c\ery year, each one knowing 



172 EXERCISE IN EDUCATION AND MEDICINE 

the feel of a rifle in his hand, and having a knowledge of its use, — 
a knowledge that never leaves him, — need not be dwelt upon here. 
The Athletic League has extended its work by the formation 
of the girl's branch. Voluntary classes in gymnastics, games, 
and dancing have been introduced among the girls attending the 
public schools, from which teachers are by no means excluded, 
many of them attending and in turn leading classes of their own. 
Exercises most popular and generally practised by the girls are the 
peasant dances of Sweden, Scotland, Ireland, and Spain, involving 
much gymnastic work and developing strength, agility, and grace. 



1 ii4. i2<s. — Relay race, Girls' Braiuli rublic S( liools Athletic League. 

Games adapted for indoor and outdoor spaces are practised, and 
relay races between classes and schools have become a favorite 
feature. 

Owing to the difficulty in finding a spacious ground for their 
athletic competitions, the Public School Athletic League has been 
the means of drawing attention to the need of good playgrounds 
in New York city. Largely through the influence of its officers, 
$400,000 were appropriated by the city for the purchasing and 
equipping of four athletic fields. Because of the enormous cost of 
land, it was impossible to procure sites on Manhattan Island, so that- 
one was built in Astoria, one at Crotona Park, another at Stapleton^ 



PHYSICAL EDUCATION IN SCHOOLS 



173 



Staten Island, and the fourth in south Brooklyn. These fields 
are equipped with running-tracks, grand-stands, and dressing- 
rooms; but if adequate provision had been made as the city was 
built, it would not have been necessary to go so far afield. 

Leagues similar in object and character have since then been 
formed in Newark, Chicago, and Cleveland. In Newark, where 
the work is particularly active, a medical examination of all 
contestants is required, about 80 boys being found physically 
unfit out of 2000 competitors. 




Fig. 129. — Field da\' for school children, Franklin Field, Philadelphia, June 20, 1908 
(Playgrounds Association of Philadelphia). 

The Playgrounds Association of Philadelphia has an athletic 
committee to organize the athletic interests of the schools, both 
public and parochial, and the first field day was held in June, 
1908, with 5000 children of both sexes taking part. It differs from 
the leagues of New York, Newark, and Cleveland by laying more 
stress on interschool competition in drills and games, where as 
many as 400 pupils from one school took part in a drill in com- 
petition with groups of 50 to 100 from smaller institutions. In 
addition to this there were group contests, relay races, and incH- 
N'idual events. 



CHAPTER XI 

PHYSICAL EDUCATION IN THE COLLEGE AND 

UNIVERSITY 

The university is the culmination of the educational system, 
but there is a distinct break between it and the school. Most 
school children go into the business or trade they are to practice 
for the rest of their lives when they leave school, and many men 
enter college who have had but a meagre experience of school life, 
and the struggle for a college education is so intense that the 
exhausting work of preparation is frequently stamped on the 
physique of the matriculant. 

The long hours of school-work, the nervous exhaustion of 
teaching, the nights spent in study, and the days in office, factory, 
or shop — all leave their imprint so deeply that the knowledge of, 
and even the desire for, a larger and fuller physical life may be 
stamped out or atrophied in the very youths whose success in 
after-life depends on the conservation and development of their 
physical powers. 

Physical education for college students must then include per- 
sonal hygiene and the correction of remediable defects, the educa- 
tion of their physical powers to the highest point of efficiency, and 
the cultivation of those social qualities that can be taught through 
the agency of athletic activity better than by any other means. 

The necessity for physical training to go hand in hand with the 
other courses of the college curriculum has always been recognized 
by advanced thinkers in the realm of college education. 

Benjamin Franklin, in writing his pamphlet, in 1749, that led 
to the founding of an academy for the education of the youth, 
now the University of Pennsylvania, expressly states that "To 
keep them in health and to strengthen and render active their 
bodies, they be frequently exercised in running, leaping, wrestling, 
and swimming" ; and nearly forty years later Thomas Jefferson wrote 
174 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 75 

to Peter Carr concerning his studies: "Give about two hours of 
every day to exercise, for health must not be sacrificed to learning." 

In drafting the plans for the University of \' irginia he did not 
forget the place of exercise, but advocated military drill and man- 
euvers as the best for the conditions then existing. 

The wave of interest in German gymnastics reached America 
about 1825, as already described in a previous chapter, and re- 
sulted in the establishment of gymnastics as part of the regular 
instruction at the Round Hill School, Northampton, Mass., and 
at Harvard College, the catalogues of 1827-28 containing the name 
of Dr. Charles Follen, "Superintendent of the Gymnasium," and 
instructor in German. These exercises were also introduced into 
Brown, Williams, and Yale, as well as many secondary schools. 

The German pioneers soon found that their status in America 
was not considered equal to the teachers of more purely intellectual 
svibjects, and soon tired of teaching boys to turn somersaults, when 
the rewards for more intellectual work were so much greater and 
more congenial. 

In i860 the first chair of Physical Education and Hygiene in 
an American college was established at xA.mherst. Its occupant. 
Dr. Hooker, was soon succeeded by Dr. Edward Hitchcock, who 
still retains the professorship, and whose measurements and vital 
statistics are the longest continuous series of observations on col- 
lege men. His conclusions, as embodied in charts and reports, 
show a consistent improvement in the student's health from the 
freshman to the senior year under his system of exercise, as well 
as an increase in muscular development. 

In 1879 Dr. Dudley A. Sargent was given the direction of the 
new Hemenway Gymnasium at Harvard, and he at once began 
the patient accumulation of vital statistics, now reduced to chart 
form and available for comparison. 

Over thirty colleges and universities have estaljlished more or 
less complete departments of physical education, in which a definite 
amount of exercise is required of from one to four classes. 

The division of physical culture and athletics was founded 
in Chicago in 1892, and in 1904 the Bartlctt Gymnasium was 



176 EXERCISE IN EDUCATION AND MEDICINE 

opened. This was a radical departure for a large university 
because there was a definite undergraduate requirement, and 
provision was made for adequate supervision and control, financial 
and otherwise, of university athletics. This made possible the 
ideal relationship between physical training proper and com- 
petitive athletics, each having its place in the complete system of 
physical education. 

The Department of Physical Education as reorganized in 1904 
at the University of Pennsylvania requires from the four under- 
graduate years, and from the primary years in the professional 
schools, except those holding a bachelor's degree, a minimum of 
two periods of exercise a week, and lectures on the application of 
exercise to disease are given in the medical course. 

A wide option is allowed, and equivalent credit is given for 
attendance at the gymnastic classes or durmg active membership 
on the foot-ball squad, crew, baseball, track, or swimming teams, 
and in the fencing, wrestling, or boxing clubs. 

In the College of the City of New York the requirement is 
much more exacting, and in nineteen of the leading universities 
this department is now on an equal basis with the others, the 
theory of hygiene and physical training forming one of the college 
courses in many of them. 

A university course in physical education should begin with a care- 
ful examination, to find the exact physical condition of the student 
and so to give an intelligent foundation on which to base advice 
and instruction. He should be measured and his strength tested, 
to see how he compares with his fellows in proportions and power. 
His posture and development should be noted, and his heart and 
lungs examined for any latent weakness or disease. The acuteness 
of his sight and hearing should be carefully calculated, for he must 
know if there be any serious obstruction of the two most im- 
portant avenues by which his knowledge is to come to him. And, 
finally, his ability to accomplish certain muscular feats that cover 
the main activities of the body should be ascertained. 

An analysis of the examination cards of 1000 freshmen showed 
that over 30 per cent, had lived a sedentary and confined life. 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 77 

while more than 60 per cent, showed some marked physical 
defect; the broken-down arch of the foot; the flat chest and 



^^^^(2>r 



UNIVERSITY OF PENNSYLVANIA 

DEPARTMENT OF PHYSICAL EDUCATION 



D.,...<^.^f*^...^.^.,..no/' . 

..^,..un....'^:...Q.M..^. 

Ace J?LQ.... jcara . . .77. montlis. 

Fnther'3 Qge . .. .77V? If deceased, age md 

Mother's age .'=!VtWr'^'f?r~~fv! If deceaBed. age ODd 

f your father's or (notber'a family Id general build?. 
Have jour father, mother, 







Consumpllon? .. ^^J^^^i'^ 
Hear.DUease7....'0^r;^.... 



Id what form, If as;, do 701 
What Is 70ur datly average! 
Do ;ou use alrohcl In any form? 




what age did you begin? 
what extent dally? 



_ o - 
o 



,, ^ 



'!>?z^-^^e.-?'?'^-^^-;>*<<5^ 



accident 1 



^-jn^ — 



■<r^- 



What Jllneases bnre kept you Id bed for two weeks ■ 
Bare ;od any renialolag effect from a prevlouB llli 
Are your appetite and digestion good? .. 

Are you subject to eoDatlpatlon? 

Have you ever bad aay disorder of the kidneys, bladder or genlto-urlnary eystem? '^?%^?^. 

Are yon aubjecl to colds Id the head ? , . , x<?:?<^rr. Throat ? . . .r<-:??r^. 

Have you any obstruction Id either nostril ? . . . . rT?:^^. . ! 

Do you suffer hnbltnally from cold banda or leetT ...<^:^^^r^. 



/^ 



:^.:.f'^Tr... 



you troubled with bilious 

■hop-. ? -'^^^ 



Have 

Write here any facts bearing 



bad Aaracbe or discharge from the 



ny trouble with your hearlns? . . .-rT?!^^. . 
past or present bealtb that may not have been covered Id the preceding qucslloi 



^9^??1fyrT7. ^. .^. . .4ff:^ f^:^"^-'^^"^'^ 



..<^^^... 



FIk- 130- — History blank filled bv the studfiit. 



protruding abdomen of the anemic school-boy, with his round 
shoulders, protruding chin, and flabby muscles, or the drooping 
shoulder and the curved spine, or the (Kill hearing and faulty 



178 EXERCISE IN EDUCATION AND MEDICINE 

sight that had been the unsuspected cause of headaches, nervous 
irritabihty, and exhaustion. 

It is the province of the department of physical education to 
bring this defective physique up to its normal level. 



UNIVERSITY OF PENNSYLVANIA 

DEPARTMENT OF PHYSICAL EDUCATION 
neoiCAi, exAMiNArioN 

.^ ..JO.:./.:.f^l :.. 

GeoBrjl Posture .'^3<ffJr?i . . . . . Slioulilen!. .-^ti^Ofif^f^iilM.T-^^S^^^ 

CbMt ..^V?f^ Abdomen.. •r^:*?rffrT?TTTr. 

Legs-E. ../^.I. L 'r^.. KMt-R.....'r^....L....frr' 

CondltloDa o( Skia . . 5^^5^'^:*r??*rT Fat. . ^-;<^^iT*?r?rTT ^ 

Veins f^TTT. Muscles... ^^^?<>rrWr^ 

. .^:<>rrr?f. BKt...^^rK?f.. 



O 



MuBculat Development of Neck ..^fYTK?r:. Back. 

Abdomen . .-f^^ ^.^. Cbeet. 

Forenrina . ^^T^T?. Tblgbs. . .J^'^T:-^ CbIv 

Heart ^^^.. '. 

Pulse Rnte, Reclining . .V. . .^(-Z. Standing tf^.TT. 

Blood Pressure, Systolic /.Q. DInfltollc. . . A .V?^?. 

Lunga ....PrfX. 

Urine (n'bi<n required) Sp. Gr Reaction Albumen Sugar 

External Condition ot Ears . K?\V Hearing : B. ...cL. L. . M. 

Remarks: 

!^:<^.'?:r':';'fr:^..'?n.'!<^.^.^/f''.f: . ..^:?>m;(^ii^:^»if^, ^ 



Fig. 131. — Form for medical examination. 

The main work of the director must, however, be devoted to 
the average man, coming from the farm, the ofhce, the factory, 
the shop, or the school, with no athletic ambitions, but wanting 
to make every moment of his time count. The college must 
provide him with enough exercise of the right sort to put and 
keep him at the highest level of physical efficiency to get the 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 79 



most good from his lectures and laboratory work, without in- 
volving too great an inroad upon his limited time. 



, MEASUREMENTS AND TESTS ^,T/ ^ ., 




lo./.oi 








1 


1 


1 




1 












i 


I""" 


1 




1 




17 












Girth-Fo™^ L 


272. 














bi<j 












Upper Arm, L.. flexed . . . 
" Thiih.R 


;?.r 














1703 












ir3 












nody UoBtb «pi«l«m.l 


/?6 














V/rl 














f/S 














V(9 












■• Ceir. 1. 


5SZ 














^('7 














1/7 












St Eth ILe 


(OS 












n3 












■• " k" 






" " AbdomcD normal 


190 












•• "4 


n.r 














3^0 















Ifff! 












Chest. nonMl. above 


9/A 1 








■■ •• Grip. R 


U 












•' Lower Cheat, expanded . . 
•' contracted . 


9'^'\ 












" Grip, L 


H 












j.7i 
ISO 












Totel Slrtnjlh 


S77 




































•* Hipa 


<io^-^ 












H '■■ 














Forearm, R., 


an 










.* W jl ^.... 
















« 
















>^-"N^ 












\? 



Fie 



132. — Measurement form. 

The athletes must also be provided for in the scheme, al- 
though they number less than lo per cent, of the total enrolment 



Date 7hrt^J6>- Ci^A. 

Name "^ ■ C- f Class 'iXr.. Dept...';?^^:,. 

Examination of Eyes: R. L. 
External Condition jfJrw*— »/,. c/- t^y'**^ \ <&£.,.. 



Muscular Balance/^. nM^JLt^^^^^^fy^^, » «fr^j2k^«r?:ife«« /z. 

Vision.,... /JrZ^ Jft.*,. 

Accommodation 4?...f?:<rf^...!r.f*,.rr..'f!f^,f!!^^ ./^..A>ro')lo-3p.. 



Ophthalmoscope,... .A:^%<i^;*^,,-./'.^ ; JfU:^^^.L.Pi<<^.. ^Jli-- 

Remark*: 7f^a/t*«y — ^ ' IS" J /-**t^ ^^jt^ftVCua^-.. 



.,..<n*^ <i^^.....h^i!^.. 







Fig. 133. — Form of eye e,\aniinalion, V. of P. 

of the college, for the severity of competition in intercollegiate 
athletics and the high standard of merit required for success 
separates them almost into a special class. 



i8o 



EXERCISE IN EDUCATION AND MEDICINE 



The average weight of a foot-ball player on a college team is 
about 174 pounds — 35 pounds more than the average man. The 
oarsman weighs about 164 pounds, or 25 pounds more than the 
ordinary student, whose height he also exceeds by about three 
inches. The light, routine exercise sufficient for the average 
student is not enough for them, and yet, while facilities should be 
given them for practising their chosen sport, the necessity of 
advice and direction, and in some cases restriction, has time and 
again been tragically shown. 




Fig. 134. — Exercise to develop the abdominal muscles on the Swedish stall bars, 
U. of P. gymnasium. 

All three classes of men, the defective, the normal, and the 
athletic, should be included in the plan of a complete depart- 
ment of physical training. 

For specific defects, prescribed exercises are required. 

Recently, a young man came to college, having been rejected 
at West Point because of flat-foot and lateral curvature. A six 
months' course of prescribed exercise, lasting about half an hour 
daily, and carried out faithfully, enabled him to pass the required 
physical examination easily. Another freshman entering on the 
study of architecture complained that he could not study on 
account of frequent headaches, especially after reading and 
drafting. His eye examination showed less than half the normal 
acuity, unsuspected and, of course, uncorrected by glasses. 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY l8l 

Hundreds of such cases come under the medical examiner's 
eye each year, and proper advice at the beginning of his course 
will prevent the appalling waste of time and energy inevitable for 
the man who struggles along with these handicaps uncorrected. 
Constant personal counsel about exercise and other questions of 
hygiene go far to add to the comfort and efficiency of these 
students. 

A course of exercise of progressing difficulty should be carefully 
designed and graded for the average man, who is neither subnormal, 
like the defective, nor supernormal, like the athlete; who has 
neither the desire nor the ability to represent his university upon 
the track or field, but who wishes to be at his highest point of 
physical vigor throughout his college course. 

A fixed requirement is essential, with credits on the basis of 
laboratory work, because a course of exercise recjuires guidance 
C|uite as much as the other subjects of the college curriculum, and 
the student's attitude will naturally be antagonistic to required 
work of any kind unless credit be given for the time taken from 
those studies which he thinks have a more direct bearing on his, 
lifework. 

Two objects must be kept in view in planning such a course: 
first, the correction of those bad physical habits that come with 
the student's sedentary life; and, second, the systematic educa- 
tion of those bodily powers that will be most useful to him during 
his college life and after graduation. 

The sudden change from the acti\'e outdoor life of the 
country-bred boy to the confinement of college work is not unat- 
tended with dangers to health, as shown by the tendency to con- 
stipation and other disturbances of digestion, headaches, and the 
other common ills for which the college medical examiner is 
continually consulted. The long hours spent in the lecture-rooms, 
not always too well \-entilated, or bent over the laboratory table, 
must also be corrected by exercises that will strengthen the tired 
back and stimulate the sluggish heart and inactive digestion, tliat 
will draw the blood from the tired brain and congested abdom- 
inal organs into the pulsating muscles and ex|)anded lungs, and 



1 82 EXERCISE IN EDUCATION AND MEDICINE 

the means used must at the same time be such as to give a real 
education to his physical powers. 

A successful course must develop those racially old coordina- 
tions that have given man his supremacy over the brute creation, 
and civilized man his superiority over the savage, for, contrary to 
popular opinion, the civilized nations are as dominant physically 
as they are intellectually. 

It is by the cultivation of the great fundamental and vital 
activities that civihzed man has asserted and maintained his 
superiority over more primitive races, and the rehearsal of these 
activities must form the basis of a course in physical education if 
it is to be interesting to the student and sound from the stand- 
point of the pedagogue. These are the exercises of locomotion, 
running, jumping, climbing, and swimming; oi fighting, throwing, 
catching, dodging; striking, and wrestling, and of cooperation 
under a leader in group games where men are organized in 
teams, individual excellence being sacrificed to the common good. 

The cultivation of physical intelligence can never lose its 
value, no matter how artificial may be the conditions of the com- 
munity in which he lives. It is what teaches a man to escape 
injury in the many emergencies of daily life; it saves what would 
be a broken arm or a sprained wrist in one who had not learned 
how to keep his feet on the slippery pavement or how to fall with- 
out hurting himself, and many costly lives are lost annually through 
inability to swim, jump, climb, or dodge. These fundamental 
actions of locomotion and fighting form the basis of all games that 
have survived to the present time, but exercise for the college 
student must be put in such form as to get the greatest possible 
result for the time expended. Games must be modified and in- 
tensified to fit the conditions of college life. It takes a field no 
feet by 60 feet to accommodate 22 men in foot-ball, 24 in lacrosse, 
or 18 in baseball, but 1000 men can be exercised in the same 
space in similar movements by arranging them for class work, 
and the course can be progressive and logical from the teaching 
standpoint at the same time. 

In the illustration (Fig- 135) a class of nearly 500 students is 



EXERCISE IN EDUCATION AND MEDICINE 



w. 




seen engaged in athletic exercise 
on Franklin Field. Each man in 
turn sprints 30 yards, clears a 
hurdle, takes a standing broad 
jump, a running high jump, and 
puts the 12-pound shot, a short 
pause taking place between each 
act. The signal is given by a 
whistle, and at each signal nearly 
100 men perform one of these feats. 

Class work should be made 
progressive in difficulty, each 
movement leading into the next 

In teaching a movement like 
rope climbing, the student should 
be first examined and marked as 
to his ability to climb a! rope by 
his arms. If he cannot do so at 
all (about 40 per cent.) , he should 
begin by pulling his weight up 
once by both arms and dropping 
to the floor. He should then 
learn to jump and catch the rope,, 
pulling his weight up several times^ 
afterward learning to catch the 
rope with the arms and legs and 
climb by the use of both, and so 
on until he is able to climb with 
ease by using the arms and legs 
or arms alone; to carry the rope 
up with him; to tie a loop in 
which he can rest, or to descend 
with one arm disabled or carrying 
a bundle. He is then reexamined 
and passed in that method of 
locomotion. 



PHYSICAL EDUCATION W THE COLLEGE AND UNIVERSITY 1 85 

The same method of teaching should be employed in swimming 
— a most important exercise — which includes, in addition to the 
various strokes, instruction in life saving and resuscitation of the 
apparently drowned. Boxing can be analyzed for class purposes 
and taught as a class drill. The position of defense, the leads, 
left and right, and guards, first simple, then in combinations, of 
increasing complexity, with and without foot work, until a good 
knowledge is obtained of this method of defense. The rudiments 
of wrestling should also be taught in the form of a gymnastic drill 
(Fig. 137), and gymnastic games should be freely used to train 




Fig. ij;. — Wrestling used as a class exercise (U. of P. gymnasium) : The chancery 

hold. 

every man to know his powers and limitations in all the activities 
of running, leaping, and climbing, while no course would be 
complete that failed to recognize the educational value, physi- 
cal, mental, and ethical, of those athletic sports that cultivate 
courage, pluck, and tenacity of purpose. 

Where possible, all such exercise should be conducted in the 
open air, or, failing that, a spacious, well-ventilated, and well- 
lighted gymnasium.^ 

^ The gymnasium should be provided with several e.xercise rooms to accom- 
modate the many activities that would otherwise clash, but where this is not 
possible, much may be done by the use of nets (Fig. 138), by which a large 
hall mav be divided into courts, and basket-ball, wrestling, and gymnastics may 
be practised without interference or danger, and the entire floor may be super- 
vised by one man. Separate rooms are necessary for fencing and boxing, and 



i86 



EXERCISE IN EDUCATION AND MEDICINE 



A year's course of exercise will, of necessity, vary considerably 
with the special conditions to be found in the college or university, 
but the following plan, which is in use at the University of Penn- 
sylvania, will be found to contain the main essentials of progression. 

October: Physical examinations and examination of eyes, in- 
struction in swimming to first year men; prescription and demon- 




Fig. 138. — Gymnasium floor divided into three courts by nets, thus permitting 
basket-ball in the central court and wrestling and gymnastics at the two ends. This 
allows of supervision of the whole floor by one man (University of Pennsylvania). 

stration of special exercises for round or uneven shoulders, con- 
stipation, flat-foot, weakness of abdominal walls, etc., given by 
the instructors on the gymnasium floor. 

November 1-25: Class work in the gymnasium. Marching 

for the indoor preliminary practice of the crew (Fig. 140), hockey team, or base- 
ball team. Corrective exercises are also better done apart from the noise and 
confusion of the main exercise hall with its constant succession of classes. 

In the practical management of classes the advantage of having the ap- 
paratus in sets of six (Fig. 139) is great. By this means the largest class may 
be so divided as to prevent the waste of time that occurs when a long line of 
men must wait their turn to perform their exercise on a single horse or pair of 
bars. 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 87 

tactics, quick time and double time; free setting-up exercises; 
gymnastic games. 

November 2^-December i: Examination on first arrangement 
of apparatus; low horizontals, climbing ropes, flying rings, and 
vaulting horse. Men are graded as a result of this examination 
into first, second, third (or leaders), and fourth (gymnastic team) 
grades. 




Fig. 139. — Gymnasium floor, showing apparatus in place for class work. Begin- 
ning with the background they are horizontal bars, flying rings, climbing ropes, and 
parallel bars arranged in gangs of six. The parallel bars are placed in floor sockets 
and can be replaced by the buck or long side horse (University of Pennsylvania). 

December i-January 27: First arrangement of apparatus, 
about ten consecuti\'e lessons on each piece, progressing in dif- 
ficulty. Drill with wooden dumb-bells. Reexamination. 

February i-March 4: Second arrangement of Apparatus. 
High horizontal bar, tumbling, buck, long horse, and |)arallel 
bars, class drill with wooden wands or Indian clubs, preceded 
and followed by examination and regrading. Indoor exhibition. 

March 4- April 1 : Third arrangement of apparatus. Pyramid 



EXERCISE IN EDUCATION AND MEDICINE 



building, boxing, or wrestling; drill with iron dumb-bells or steel 
wands; dancing steps. University circus given by the leader's 
corps. 




Fig. 140. — Indoor practice for crew candidates during the winten in preparation for 
actual rowing on the river. 




Fig. 141. — The building of pyramids as a class exercise, U. of P. gymnasium. 

April i-May 5: Athletic sports indoors or on Franklin Field 
when possible. The start in sprinting; hurdling; broad and high 
jumping; putting the shot; running and dancing steps. Outdoor 
exhibition of the united classes. 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 89 



Alay ^-June 1 : Physical examination of the graduating class. 
It is found that, after two or three years of the regular educa- 




-A class drill in free movements and elementary dancing steps, \] . of P. 
gymnasium. 

tional classes, men take up specialties and devote themselves to 
advanced boxing, wrestling, fencing, or swimming, or join the crew, 
football, or baseball squad. A certain standard of excellence is 
required to get credit for these specialties, however, and many try 
for the teams, and, failing, drop back into the class work. 

The following table shows the distribution of men in the dif- 
ferent sports and in the gymnastic classes at Pennsylvania: 

Approximate Distributiox of Men Doing Required Work in Different 
Forms of Exercise During a College Year at Pennsylvania. 

Prescription work for defects or disability 300 

Regular gymnastic classes 1096 

Reporting for baseball 120 Retained on baseball squad.. . 70 

70 " " basket-ball team . 16 
14 ". " bo-xing team 14 

71 an crew 46 



basket-ball 70 

boxing.. . ., 14 

crew 71 

fencing 32 

football 123 

gun club 7 

gymnastic team . 16 

soccer 42 

swimming qg 

track 283 

wrestling 83 

Total g6Q 



" " fencing team .... 8 

" " football squad ... 77 

" " gun team 7 

" " gymnastic team . . 9 

" " soccer iS 

" " swimming 28 

" " track 66 

" " wrestling 12 

Total 368 



Grand l(jlal 2365 



190 EXERCISE IN EDUCATION AND MEDICINE 

The actual conduct of competitive athletic sports may, to a great 
extent, be left in the hands of the students themselves as a part of 
their social training, but the university should require two things: 
a careful examination of the physical condition of competitors 
before allowing them to enter their name on the squad; and a 
rigid standard of scholarship for all who are to represent the in- 
stitution in an intercollegiate contest. 

The number of men who are prevented, by a preliminary 
medical examination from endangering health or life, shows the 
value of this precaution wherever the more violent forms of ath- 
letics are practised, and men sometimes present themselves as 
candidates for athletic teams who have unsuspected organic lesions 
of the heart, dangerous hernias, or incipient tuberculosis, men who 
have no place in the exhausting struggle of a game of football, a 
boat-race, or a half-mile run, but to whom regular judicious light 
exercise would have the greatest value. 

The medical examiner should, of course, have complete author- 
ity to decide on the best course to pursue in each case, and he will 
usually find, with added experience, that he may permit many a 
man to engage in vigorous sports, with advantage to his health, 
whose condition would be condemned by one who went entirely 
by the standard text-books. This question will be more fully dis- 
cussed in the chapter on Disorders of the Circulation. 

The question of scholastic and amateur standing is scarcely 
within the scope of this chapter, but some universities require even 
a higher standard among their athletes than in the general student 
body, and the tendency of most academic councils is in the direc- 
tion of greater stringency in the rec[uirements and a more rigid 
enforcement of the regulations. 

In rough games like football there will always be accidents 
to deplore. The chance of a twisted ankle or knee, or even a 
broken collar-bone or arm or leg, is one of the things that make 
such games attractive to the healthy young man, but if we put 
against these accidents the escapes that every old player of forty 
can recall from an injury that a clumsy slow movement would have 
precipitated, the balance will surely be on the other side, and the 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY I9I 

permanent disability from accident is almost negligible in men 
who, properly examined, and found to be sound, are sent into 
a contest in good physical condition by an adequate course of 
training. 

Practically all colleges and universities that have such a de- 
partment organized give some instruction in the theory of physical 
training and personal hygiene, their courses forming part of the 
regular teaching, either elective or compulsory, as the special con- 
ditions seem to indicate, and the application of exercise and 
massage in medicine and surgery now has a recognized place in 
every well-equipped medical curriculum. 

A summer course, lasting six weeks, for students and teachers 
of physical training has been given for the last twenty years at 
Harvard. It began with a one-season course, and now extends 
over three summers, and includes both theory and practice, and 
summer courses are also given at Columbia University, the Col- 
lege of the City of New York, and at Chautauqua. Owing to the 
imperfect and superficial training received by most teachers of 
this subject, these summer schools are most valuable and de- 
servedly popular. 

In addition to the supervision of the health and the teaching 
of the students, a department of physical education has unusual 
opportunities to promote original research in the problems of 
psychology, physiology, and anatomy that confront it, and the 
association of other departments in solving them should not be 
neglected. 

The taking of certain measurements from time to time is 
useful to stimulate in the student a pardonable pride in his 
expanding chest and swelling biceps, but it is also of use to 
determine the proportions of the average student and his varia- 
tions from this ax'erage. 

Hitchcock, Seaver, and especially Sargent have done pioneer 
work on this subject. 

Dr. Sargent's complete set of charts, containing the principal 
measurements of students for each year, from sixteen to twenty- 
live, and selections from liis statistics for the youth and maiden 



192 



EXERCISE IN EDUCATION AND MEDICINE 



of twenty-one, have been embodied in two life-size statues, 
modelled by Henry H. Kitson, showing the medium measure- 
ments for that age. 




Fig. 143. — The ideal college athlete. 
(Copyright, R. Tait McKenzie.) 

The variations from that type have been noted by Paul C. 
Phillips in his observations of sprinters,^ by the author in 

. ^ "Outing," May, 1903. 



PHYSICAL EDUCATION IN THE COLLEGE AND UNIVERSITY 1 93 

speed skaters/ and by Dr. Sargent in his '^ Physical Proportions 
of the Typical Man " and " Physical Characteristics of the 
Athlete." - 

The search for a physical ideal was undertaken by the So- 
ciety of Directors of Physical Education in Colleges, who, in 
1902, commissioned the m.odelling of a statuette embodying the 
average measurements and proportions of the pick of the student 
body, selected by taking the best fifty men in the all-around 
strength test for a period of eight years. These four hundred 
sets of measurements of Harvard students, supplied by Dr. 
Sargent, were used to determine the proportions of the " ideal 
college athlete" (Fig. 143), who is represented as placing in his 
right hand the spring dynam,om_eter with which he is about to 
test his grasping muscles. 

This youth may be said to embody the proportions and 
girths of the physically ideal American student of twenty-two. 

With a height of 5 feet 9 inches, he carries a weight of 
159 pounds. The girth of his neck, knee, and calf are the 
same, with the upper arm i^^ inches less. The girth of his 
thigh is J inch less than that of his head. His expanded chest 
is 40 inches and the girth of his waist is 10 inches less. His 
hip-girth is almost the same as his unexpanded chest, while the 
breadth of his waist barely exceeds the length of his foot, and 
the stretch of his arms measures 2 inches more than his height. 

^ "Popular Science Monthly," December, 1905. 
^ "Scribners," July and November, 1887. 
13 



CHAPTER XII 

THE PHYSICAL EDUCATION OF THE BLIND AND 
THE DEAF-MUTE 

Having described the physical education of the normal child 
from infancy to maturity, there remains only a description of the 
modifications required for the training of those unfortunates to 
whose minds the avenues of sight and hearing are closed; and of 
those others whose minds are dulled or who have already taken 
the first steps in the path that leads to the penitentiary or the mad- 
house. 

Since the world of the blind is limited by the horizon made 
by the reach of his arms, his supremacy within this circle must be 
supreme. 

Physical education does him a triple service by increasing 
the courage and confidence which he so sadly lacks by develop- 
ing his muscular powers and by fortifying his body against those 
infirmities to which enforced idleness and a sedentary habit render 
him peculiarly prone. 

It is within comparatively recent years that the physical educa- 
tion of the blind has been studied with care, and that methods 
have been adapted to their possibilities and limitations. 

The most strikinsr characteristic of, the blind child is a certain 

o 

timidity or fear of appearing at a disadvantage before others, es- 
pecially in making an unaccustomed movement, so that the only 
exercise they undertake voluntarily is walking backward and for- 
ward in some confined place with which they are familiar. They 
are liable to sit stillfor long periods of time, and usually develop 
certain rhythmJc habit movements of the head and hands, difficult 
to repress and correct. 

They must either feel or hear a movement in order to learn it,. 
194 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE I95 



for they have not the mirror 
of their companions from 
which to correct faidts in their 
own posture or action. 

In the measurement of 
boys at the Overbrook School 
for the Blind it was found 
that their height, weight, and 
lung development were under 
the average of normal boys 
of the same age, as shown 
in the Sargent charts (Allen). 
The blind boy has thus even 
a greater need for physical 
training than the boy who can 
see. 

In many blind children ex- 
ercise must begin with the 
simplest acts, such as dressing 
and undressing, which have 
been neglected in many homes 
where the blind child is waited 
on and not trained in move- 
ments that make for accuracy 
and tidiness. 

A course must pay special 
attention to the improvement 
of posture in walking, stand- 
ing, and sitting, for the blind 
walk \\ith the head inclined 
forward, the chest contracted, 
and usually come down hard 
upon their heels at each step, 
and it must embrace free move- 
ments for the chest, arms, and 
shoulders, including all possi- 



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196 



EXERCISE IN EDUCATION AND MEDICINE 



ble games and other forms of reaction that can be conducted 
with safety and abandon. 

The chief difficulty in a course is the cukivation of that 
physical confidence necessary for success in active sports like 
running, jumping, and gymnastics. 

Various devices are required in the construction of the gym- 
nasium and field to prevent accidents and to foster freedom of 
movement. The gymnasium hall should be constructed with a 
wooden floor, surrounded by a band of cement seven feet wide, 




Fig. 145. — The mtk-rifrht and olher tfyninastic games. The band of mncrete at 
the edge of the floor is also shown. (Pennsylvania Institution for the Instruction of the 
Blind, Overbrook, Pa.) 

on which all the heavy apparatus should be placed when not in use 
(Fig. 145). In this way a blind person is made aware of his ap- 
proach to the wall, and of the presence of danger, when walking, 
running, dancing, or skating. A running track should have a 
hand-rail of convenient height to serve as a guide, and in the play- 
fields the presence of trees should be shown by having a brick 
walk about ten feet in front of or around them,, so that the child 
may run and play with perfect freedom and confidence until 
warned of the approach to danger by the bricks under foot 
(Fig. 144). 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE I97 



Outdoor apparatus should also be lixed, the child soon learning 
their place, and avoiding the collisions that would inevitably occur 
if their position were a matter of conjecture. 

Physical education for the blind should be compulsory at all 
institutions as it is at Overbrook, Pa., the classes being small 
and arranged in the order of their age, and with some partially 
blind pupils mixed with the totally blind to act as leaders. The 
formation of a class in the gymnasium need not differ very much 
from that of children with sight, except that in lining up they 
should keep in touch with one another by each pupil placing the 




Fig. 14O. — Method of alignment in a class of the blind in Sweden (Lefebure). 

hand on the shoulder of the one in front, or, where a class is 
formed up in ranks, by placing the right hand on the companion's 
shoulder and the left hand on the waist, as is done in Sweden 
(Fig. 146). 

When a num.ber are lined up in single file a regular class 
formation can be obtained without difficulty by giving t*he order 
"right turn,' and counting off, and this can easily be reversed to 
the original linc-u}) when the exercises are over. 

Gymnastic ajjparatus work may be used with considerable 
advantage, but the leader should be able to sec a little, and mem- 
bers of the class must learn the movement by passing the hand 



198 EXERCISE IN EDUCATION AND MEDICINE 

over the leader while he is doing it. By this means a wide range 
of work can be done on the horse and parallel bars, and such ex- 
ercises as falling, rolling, and simple tumbling may be extensively 
developed, but the Swedish system of gymnastics, in which the 
exercise is performed in response to command, must be used 
sparingly, because of the great and rapid mental exhaustion pro- 
duced in blind children. 

Formal gymnastics and apparatus work should play, however, 
a comparatively small role in their day's exercise, and games should 




Fig. 147. — 100-yard dash. Start, showing handles and cables to direct their 
course. Overbrook record, lof seconds (Pennsylvania Institution for the Instruction 
of the Blind, Overbrook, Pa.). 

be freely interspersed when symptoms of exhaustion appear. 
Among the most popular games are the cock-fight, and a game 
invented at Overbrook by Lindblad, called the Japanese 
torpedo, in which a small bag of sand covered by emery cloth is 
attached to a long string, and swung around in a circle by one pupil 
while the others jump over it as it passes, being guided by the sound 
of the emery cloth on the floor. 

Running, roller-skating, and dancing can also be practised if 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE I99 

comparatively few skaters or dancers are allowed on the floor at 
one time, and all are required to circle in one direction only, the 
presence of the concrete margin on the floor being sufficient pro- 
tection when heavy apparatus is carefully put back in its place 
against the wall after class use. Another protection against run- 
ning into the wall is the changed resonance due to the presence of 
the running track, a phenomenon which the blind use continually 
for their protection. 




.' ._. , -V .. — I ; :-;, .11'. -i.,-/,. I'i, .,-!,. Tlic racers arc aMc to give unhampered 
attention to speed by means of the device shown above. Upon the wire cables, stretched 
the full length of the track, are rings to which are attached short chains and handles. 
The racers hold these handles and run the course with perfect freedom. They are 
warned of the end of the track by the fringe of cords like that used on railroads to notify 
brakemen on top of freight cars of "low bridges" (Pennsylvania Institution for the In- 
struction of the Blind, Overbrook, Pa.). 



x\mong the outdoor sports walking is almost the only one blind 
children will voluntarily undertake, although they can *be taught 
almost all the field sports, with but few restrictions. 

Clarence E. Van de Walker, the instructor at Overbrook, 
writes on this subject: 

"To me, watching and directing tliis work from day to day, 
the sight of strong, acti\"e boys learning to run in much the same 



200 



EXERCISE IN EDUCATION AND MEDICINE 



way that a baby learns to walk, and experiencing about the same 
difficulties, was both amusing and pathetic; but the smile and shout 
of triumph which burst forth simultaneously from the boy who had 
succeeded in really running were ample proof of his delight to 




Fig. 149. — Blind boy preparing to jump. 

discover that he possessed a power dormant so long that he doubted 
its existence." 

Foot-racing was practically impossible imtil the invention of a 
method in one of the institutions of Edinburgh, by which a three- 
stranded cable as light as was consistent with strength was stretched 
breast high between well-guyed end-posts no yards apart. The 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 20I 

runner holds in one hand a wooden handle attached by a short 
flexible chain to the long wire. As he runs the ring slips along and 
the feeling and sound enable him to hold his course. At the end 
of the loo yards a cord is stretched across, about seven feet high, 
from which hangs a fringe of hammock twine long enough to strike 
the runner in the face as he passes. This fringe covers the two 
p,arallel lanes, so that competitors may run in pairs, and prevents 
those accidents that were at best too frequent in the open lield. 




Fig. 150. — Putting the shot (12 lbs.)- Overbrook record, 35 ft. i^ in. (Pennsj'lvania 
Institution for the Instruction of the BUnd, Overbrook, Pa.). 



Even the running broad jump may be practised, the measure- 
ment being made from the starting foot instead of from a fixed 
board. 

Other popular field sports are putting the shot, thro.wing the 
discus, and throwing the hammer — with a stiff wooden handle and 
thrown from a stand. 

A strange ])hcnomenon for the psychologist is the popularity 
of a modified form of baseball, in which, at a signal, the pitcher 
throws the ball, the batter strikes, and the catcher catches. As a 
rule, no one accomplishes anything 1jut the ])itchcr, and yet l^oys 



202 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 151. — The swimming pool (Pennsylvania Institution for the Instruction of the 
Blind, Overbrook, Pa.). 




Fig. 152. — Trolley coasting on the athletic field (Pennsylvania Institution for the Instruc- 
tion of the Blind, Overbrook, Pa.). 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 203 




Fig. 153. — Ring game. Kindergarten building in the background (Pennsylvania 
Institution for the Instruction of the Blind, Overbrook, Pa.). 




Fig. 154. — .\ game of "blind man's buff" in the girls cIoLsUt (rmii.sylvaiii.i, lii.-^iiiulion 
for the Instruction of the Hlind, Overbrook, Pa.). 

will play this for hours at a lime. Football is also ])layc(l by choos- 
m^ sides and kicking the ball l^ack and forth until the .t^^oaldine of 



204 



EXERCISE IN EDUCATION AND MEDICINE 



one side is crossed. This is also popular, and can best be done by 
choosing one, at least, on each side who has partial sight. 

Swimming is an excellent exercise for the arms and shoulders, 
and is practised with success among the blind. 




Fig. 155. — Rocking-boat (Pennsylvania Institution for the Instruction of the Blind, 

Overbrook, Pa.). 

Athletic sports are quite as popular among the girls as they are 
among the boys. They enjoy jumping and running, and athletic 
and gymnastic apparatus, like the trolley-coaster, swings, and see- 
saws, should be provided for them in the gymnasium and out-of- 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 205 

doors, while the rocking boat is safe and an endless source of 
pleasure to the younger children. 

The Deaf-mute. — A system of physical training designed 
for deaf-mutes must take into consideration the peculiarities in- 
cident to deafness that divide them from the rest of humanity into 
a class by themselves. And it must also bear in mind the fact that 
in almost every respect they resemble other children. A deaf 
child thinks in gesture and pictures, and so expresses his thoughts, 
but his verbal memory is undeveloped. His chest and all the ap- 
paratus of articulation are, in consec^uence, under the average, and 




Ficr. 1^6. — Deaf-mute^ iila\iiii,' 



they are peculiarly liable to disorders of the respiratory tract accom- 
panying this underdevelopment. 

In girls of sixteen one series of observations by Miss Grace 
Green showed an average lung capacity of 118.3 cubic inches, as 
compared with 130 cubic inches of the normal girl of the sam.e age. 

Their powers of coordination,, particularly of equilibrium, 
are not up to the normal, and they have a peculiar characteristic 
slouch of the figure and a shufi^ing gait. 

Physical education woulfl then include and emphasize the 
teaching of articulation, which is an art by itself; the develop- 



2o6 EXERCISE IN EDUCATION AND MEDICINE 

ment of the respiratory system; the cultivation of balance and 
the correction of postural defects. 

The education of the deaf is carried on better in an institution 
than at home, and as the great majority of such cases come from 
the poorer classes, and have to be made as efficient as possible 
as wage-earners, I shall write more particularly of institutional 
work. 

No formal drill should be given to the very youngest pupils, 
who have no " language, ^^ but games and free play seem to suit them 
best. To the class next youngest, whose language is limited, work 
should be given by word of command, followed by the execution 
of the movement, which the children imitate. In this way the 
movement of the lips is associated with the exercise, and the child 
is trained to read the lips in such wise as to learn the response to 
the command without further demonstration. 

The teaching of lip-reading is part of the instruction in every 
institution for deaf-mutes. 

The last census of the United States shows that of 89,287 deaf, 
only 13,986 could read the lips, and speech-reading was confined 
almost entirely to the totally deaf, since the partially deaf or those 
who have acquired deafness in later life do not learn it, but depend 
on the use of some device like the ear-trumpet in preference. 

About 39 per cent, of the totally deaf have been taught lip- 
reading at institutions like Mount Airy, Pa., and elsewhere, and 
as every means is taken to practise the children in this art, physical 
training gives valuable opportunities. 

In the more advanced grades, as their language becomes better, 
the significance of the command is apprehended and its full meaning 
realized. Exercise by word of command is then of double value 
for deaf-mutes, since it teaches lip-reading and trains their verbal 
memory. There are two things to be remembered, however, in 
teaching a class of deaf children. The teacher must always be in 
front of the class, on a platform elevated at least one foot above the 
floor, so that each pupil may have a clear view of her mouth with- 
out having to lose the correct attitude in standing. Commands 
for marching and turning movements must always bring the class- 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 207 

back to a position facing the platform, as the pupils have only the 
teacher's face to depend upon for direction. Her face should be 
well lighted, and the commands should be given with full force, so 
that the natural facial expression may be maintained. This, while 
an advantage, is not essential, as I have repeatedly seen a class 
respond promptly and accurately to a command given by the lips 
only without any sound. 




Fi'.. 



gymnasium at Mount Airy, showing the hahmce Ijoards for teaching 
equiUbrium, in the foreground. 



The shuffling gait and bad posture are corrected by setting-up 
exercises, taken in the standing and sitting positions. Close 
attention should be given to the correct carriage of the head and 
shoulders; to the rhythm and length of the stride; to the ])Osilion of 
the feet and the distribution of the body weight. 

Balance movements are most useful for encouraging a Ijctter 
equilibrium and impro\'ing the manner of walking, rccjuiring, as 
thcv do, a hi!j;h dei^ree of coordination. W'hethcr a hick of coor- 



208 EXERCISE IN EDUCATION AND MEDICINE 

dination and equilibrium is or is not a direct result of deafness is 
not proved, although in many cases it would appear to be the case. 

In a series of experiments conducted by Miss Grace Green, at 
Mount Airy, 60 pupils were chosen from the intermediate depart- 
ment of the institution on account of their untrained sense of equi- 
librium. From this number 16 were excluded, classed as semideaf. 
Of those remaining, 27 were congenitally deaf and 17 were semi- 
mutes. Of the 27 congenitally deaf, 20 could sustain equilibrium 
with little difficulty and 7 could not, while of the 17 semimute, only 
2 were able to keep in balance. 

It is also worthy of note that of the 44 cases, 32 were unable to 
maintain equilibrium on the balance beam or board. 

These experiments emphasize the importance of balance ex- 
ercises in the training of the deaf, for they rapidly respond to sys- 
tematic training. 

Deaf-mutes do not compare fa^'orably with hearing people in 
the matter of longevity. They die in a larger proportion from dis- 
eases due to bad feeding, poor housing, and unsanitary conditions. 
Mouth-breathing is exceedingly common among them, and there 
is a high mortality, due to chronic affections of the respiratory 
tract. Great emphasis should thus be laid upon good food, warm 
clothing, the cultivation of speech, and the use of respiratory exer- 
cises, both free and by the aid of apparatus. 

It is to be remembered that one of the chief characteristics 
of the deaf is the lack of speech. The hearing child who is laughing, 
singing, and shouting in his play all day is unconsciously giving 
to the lungs one of the most healthful exercises. The power of 
speech is a great incentive to the Use of the lungs, and the ac- 
quirement of speech, one of the first things that should be 
taught the deaf child, can be greatly aided by exercises of deep 
breathing, together with movements of the arms, chesty abdomen, 
and lateral trunk, with special training in tone production and 
control of the respiration. The patient is thus given increased 
power to resist disease, and acquires better speech through this 
development of the entire respiratory tract. 

Miss Green has shown at Mount Airy a rapid and gratifying 



PHYSICAL EDUCATION OF THE BLIND AND THE DEAF-MUTE 209 

increase in the chest capacity of the girls of that institution under 
the influence of physical training and instruction in articulation. 
Her pupils showed an average lung capacity of 118.3 cubic inches 
on entrance, in comparison with the average 130.3 for normal girls 
of the same age. With training the average was raised to 139.6 
cubic inches from one season's work. 

Games and play are used freely, both to relieve the tedium of 
the more formal gymnastic work and to give that development 
which can be produced by free play alone. They differ little 
from the plays of the normal child, and should be designed so as to 
involve the actions of large muscle groups, training the children 
in alertness, decision, and accuracy. 

For boys and young men all the games and sports of the normal 
child are available, and it is not uncommon to see the football or 
basket-ball team of such an institution taking its place with that of a 
preparatory school or college of the same size, although the silence 
with which they play forms a striking contrast to the noise of their 
opponents. 



14 



CHAPTER XIII 

PHYSICAL EDUCATION OF MENTAL AND MORAL 

DEFECTIVES 

It is during the early years of school life that the condition 
known as mental dulness, backwardness, arrested development, 
or feeble-mindedness develops sufficiently to be capable of definite 
diagnosis. It is there also that the first steps can be taken to correct 
mental sluggishness and to train the neuromuscular system of 
these atypical children. 

The backward child is always much older and bigger than the 
children of his class, hopelessly behind in his standing, usually 
remaining two or three years in the one grade, and sometimes 
promoted only when the desks and seats of the room have become 
too small for him. 

Any child that is not able to profit by the ordinary methods 
of instruction given to the other children of his age should be con- 
sidered backward or defective, and all such cases should be carefully 
observed, and a record of their habits and mental characteristics 
should be made in cooperation with the medical inspector, or, if 
necessary, with an expert on mental conditions. A thorough ex- 
amination should be made of the special senses and throat; ade- 
noid growths where found should be removed, and defective vision 
or hearing corrected. The removal of these remediable obstruc- 
tions is frequently sufficient to permit the backward child rapidly 
to regain his normal grade standing. 

Mental dulness may be due also to physical weakness following 
severe illness, or to other curable conditions that may not have been 
recognized by the parent or family physician. Again, certain 
children in good physical health develop slowly at certain stages, 
afterward catching up with their fellows. This may be due to a 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 211 

period of rapid physical growth, and should be carefully distin- 
guished from the more serious conditions. Teachers all recognize 
a class of children who remain distinctly backward for se^■eral 
years. When they wake up, as they eventually do, they frequently 
show unusual ability. When these cases are accounted for, and 
their types of temporary slowness or abnormality noted, there still 
remains a group of pupils who, while not actually idiotic, are 
so deficient mentally as to be entirely incapable of profiting by 
ordinary school methods. 

In the examination of 100,000 London school-children. Dr. 
Francis Warner, in 1890, showed over i per cent, of actual mental 
defectives, and similar investigations show that this ratio holds good 
in America. 

The symptoms of mental deficiency are characteristic. Back- 
ward children are fatigued by any mental effort and lose interest 
quickly. They are not observant, are not able to discriminate 
quickly and accurately color, form, or size. They may be unduly 
idle and listless or overexcitable. They are often disobedient,, 
wilful, and liable to attacks of stubbornness and bad temper^ 
They are untidy in their personal habits (Fernald), awkward in 
their gait, movement, and attitude. In grasping, they are either 
feeble or they may clutch the object and seem to be unable to let 
it go. Incoordination is plainly shown in drawing and writing, in 
the lack of skill and dexterity in simple gymnastics, and in the 
lack of initiative and spontaneity. They do not show the strength, 
vigor, alertness, and courage of normal childhood. 

When a diagnosis has been made, the parents should be frankly 
and tactfully taken into the teacher's confidence, the use of op- 
probrious terms to express mental defectiveness being carefully 
avoided. The parent should be impressed with the fact that the 
child is not doing well at school and that for his own sake he should 
have special attention to prevent him from going backward, as well 
as to train to the best advantage such powers as he has. 

Slight cases of backwardness may be taught in classes com- 
posed of children who show about the same degree of retardation, 
while pronounced anrl incurable cases are much l)etter safe- 



212 EXERCISE IN EDUCATION AND MEDICINE 

guarded in an institution where they can be more closely ob- 
served and protected. 

The physical education would then vary with the degree of 
the defect and with the amount of control exercised by the teacher. 

In a school system special classes should be provided for them, 
and teachers should be specially prepared to take charge of these 
atypical pupils. Public schools for them have been in successful 
operation in Germany, Norway, Sweden, Denmark, France, 
Switzerland, and England. In London alone there are more than 
60 classes, and such classes are also in successful operation in 
Philadelphia, Providence, Boston, Chicago, and elsewhere. 

Backward children are segregated for their own benefit, and 
also for the benefit of the other pupils of the school whom they 
would hold back. The classes should be small — not over 15 
in number — and great attention should be paid to improving 
the child's surroundings in the home as well. His physical 
condition should be kept as favorable as possible by nourish- 
ing food, regular outdoor exercise, bathing, ample sleep, and 
careful attention to bodily functions and habits. The mental 
awakening resulting from an improved state of nutrition and 
bodily vigor alone is often striking. The education of the 
special senses and the training of the voluntary muscles to 
prompt and accurate response must precede and prepare the way 
for the more purely intellectual training. The unseeing eye, the 
unhearing ear, and the other obstructed avenues of approach to 
the central intelligence must be opened up by a series of carefully 
arranged "sensorial" gymnastics. The ultimate aim of these 
exercises is to train the child to acquire knowledge from his sen- 
sations. Next in importance comes the discipline of the muscles, 
not only for muscular growth and practical coordination, but 
particularly with reference to the well-recognized relation of 
thought to muscular movement, motor training being one of the 
most potent factors to arouse the feeble powers of voluntary at- 
tention, observation, and comprehension. This motor education 
should begin with the common games and occupations of normal 
childhood. The child should be taught to throw and catch a ball. 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 213 

to kick a foot-ball, to jump and run, and, in fact, to perform larger 
movements calling for the natural use of the various muscle groups, 
progressing with an eye to the normal evolution of the play in- 
stinct as described in the chapter on Age and Occupation. 

Music and rhythmic marching are preferable to more formal 
gymnastics, involving close and continued attention, prompt 
obedience, and accurate motor response. These qualities must be 
cultivated by the simplest movements at first or the good effect will 
be lost. Gymnastics by commands would at first be entirely 
beyond most of these children, whose attention would quickly lag 
and whose cooperation and interest it would be impossible to 
maintain. 

What has been said of general motor training applies with special 
force to the training of the finer coordinations of hand and forearm. 
This can best be done by kindergarten methods and by manual 
occupations, such as Sloyd, basketry, and weaving. Indeed, 
there are no other means of influencing so profoundly the men- 
tal growth of the defective. Instruction must always begin 
on a very low plane and progress at best will be slower than in 
the normal child. At an early age much of this neuromuscular 
training by gymnastics may be directed to the various handicrafts 
and simple manual labor which will enable many of these children, 
especially in institutions, to become self-supporting in after-life, 
who would otherwise become a burden on the community. Under 
this course of education some children develop up to the grade 
classes and return to them, completing a fairly satisfactory school 
course. When, however, the degree is extreme and the condition 
is congenital or the result of disease or injury, these brain abnor- 
malities remain permanent conditions, and no really feeble-minded 
person was or can be entirely cured (Fernald). 

It is always a question of how much improvement is possible 
in each individual case. Many of them may be trained to be at 
least self-supporting, if not self-controlling, but the greater number 
need oversight and suj^ervision as long as they live. A large pro- 
portion become public charges, anfl it is important that they be 
kept in institutions as they approach arlult life, that they may not 



214 EXERCISE IN EDUCATION AND MEDICINE 

have an opportunity to yield to the physical temptations to which 
they are so peculiarly susceptible, and so propogate their own kind. 

Cases of gross defect are always better treated in institutions 
than at the school or in their own homes, but even in aggravated 
cases much can be done by motor training to improve their bodily 
habits and to increase their range of usefulness, making them more 
observant and appreciative of their surroundings. According to 
Barr's experience, the best results are obtained from military drill, 
games, and gymnastics, with manual training varying in difhculty 
with the grade of backwardness, the relationship of the grades 
in mental defectives being somewhat like the successive ages in 
children so far as their helplessness is concerned. The lower grades 
are like the youngest children, but their physical conformation 
does not correspond with their mental backwardness. 

The more educational movements should be directed, first, 
to the posture and gait of the patients. Their most characteristic 
defect is the shambling walk, with dragging feet and slouching 
figure. This may be corrected by running to command up or 
down hill, by walking contests on tip-toe indoors or out-of-doors. 

Such exercises, briskly carried out, awaken the attention and 
make a good break in a long occupation period. 

The use of a springboard, supplementing walking drills, 
develops elasticity in the dragging step. Stooping may be cor- 
rected by balancing a book or basket on the head, and the poise 
and ease of bearing thus improved. The placing of a ladder 
horizontally on the floor is a valuable way of correcting a slouching 
gait. The child steps between the rounds, and must raise the foot 
well at every step. The stepping on bricks placed at regular dis- 
tances is another device for the same purpose. 

Military drill has a peculiar educational value for a defective 
(Barr). The boy learns a certain standard of precision, at- 
tention, and readiness of movement. The emulation brought 
about in these movements is important. The stimulation of his 
ambition to attain to the power of the others; to present arms in 
order that he may not disturb the general movement of the squad, 
is also one of the most important means of character building. 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 215 

This discipline is also obtained by gymnastic exercises in which 
prompt obedience to command is insisted u|)on. These drills 
should be practised only for a few minutes at a time, and varied in 
difficulty to suit the grade of the class. The training for skill and 
coordination of the arms and hands (Fig. 158) may be accom- 
plished by the horizontal and parallel bars and the use of ladders 
for climbing. 

One of the most defective coordinations in the atypical child 
is found in the power of grasping. The weak and ner^'ous lingers 




Fig. 158. — Defective class. Nine to fifteen years. First grade work. Sideward 
bending, showing the poor coordination in the carriage of the head and arms 
(Krogh). 



of the untrained imbecile can retain nothing within its grasp, or 
the nervous clutch, unconscious of its violence, is equally expressive 
of mental incapacity. 

It is necessary, then, to train this coordination by simple and 
strong exercises of hanging and climbing, catching and throwing, 
before giving to the child a hammer, a saw, or a chisel. The 
throwing and catching of balls, from the baseball to the medicine 
ball, are useful, as are the simpler exercises on the bars and rings. 

In high-grade defectives this power of regulating the grasp is 
better controlled, but it may be still further trained by weaving. 



2l6 EXERCISE IN EDUCATION AND MEDICINE 

club-swinging, or blackboard drawing with both hands, after the 
system of J. Liberty Tadd. 

Active sports are to be warmly encouraged, the exhilaration to 
the onlookers as well as to the participants being a good antidote 
to the lethargy and the timidity of the feeble-minded. The cir- 
culation is stimulated thereby, and the muscles, which are in- 
clined to be flabby and cold, are improved in nutrition. 

Dancing is an amusement in which most of these children 
delight, and many excel, and its good effect is evident at once. 
Running, racing, swimming, leaping, vaulting, quoits, tennis, 




Fig. 159. — Crippled and defective children gardening (Playgrounds Association of 

Philadelphia). 

croquet, are all most suitable, while football, baseball, and basket- 
ball are frequently well played and eagerly discussed by children 
even of a very low grade, but lack of initiative is the outstanding 
characteristic of the great mass of incapables. 

During a recent visit to an institution for the feeble-minded a 
group of boys were seen working in the field. Their attention 
being attracted, they all stopped, some with bent back about to 
lift a shovelful of earth, others in various stages of arrested 
movement. Thus they remained until called back to their work 
by the shout of the foreman. This mental apathy expressed by 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 217 

sluggish physical movement is present in nearly all low grades of 
intelligence, and can only be reached by such means as have been 
described. 

The other type of mental defectives shows an abnormal exci- 
tability, seen in restlessness, insubordinatiDn, and truancy, and it 
is these children that so frequently find their way into the Juvenile 
Court, the reformatory, and the jail. 

Blunted intellect and moral failure, as a rule, go hand in hand, 
and it is a mistake to suppose that the criminal child or man is 
naturally bright. If apparently bright, it is usually in a narrow 
line and self-repeating — more allied to animal cunning than to 
intellectual power. He is vacillating, without fixed purpose or 
aim, incapable of pursuing a consistent plan, and of a rudimentary 
or atypical mental development. 

Physical training, then, is specially indicated in the case of the 
youthful delinquent who so often enters the school for delin- 
quents poorly nourished, anemic, with muscles soft and flabby, 
from a life passed in the dark and unsanitary tenement house, 
homeless on the street, or uncared for in the village. Along 
with this common city type there will also be fcund in the Juvenile 
Court or special training school the apathetic dullard, stupid 
and shambling, whose every motion expresses mental lethargy 
and physical incapacity. As a rule, these cases detest exercise 
or anything that disturbs their stupor, and for them discipline 
must be Spartan in character, for exercises need not be agreeable 
to be beneficial, as has been well insisted upon by Sargent and 
is daily proved in the reformatories. 

A course of physical training for such children acts beneficially 
in three ways : By awakening the brain activity of those who are 
mentally defective; by bettering the badly nourished and flabby 
muscular system by developing the heart and lung power; and 
by demanding alert and promj^t response to command, a most 
important lesson, to be taught so well in no other way. 

The course of training for the incorrigible youth or young 
criminal would begin with military drill, in which the boys are 
formed into companies with sub-officers selected from their own 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 219 

number. These companies are taught the usual evolutions of 
marching, countermarching, and the manual of arms. The 
authority of the officers selected from among the boys should cease 
with the end of each drill, and promotions should be made with the 
greatest care. There is always a temptation to bully if the giving 
of this temporary authority is not rigidly guarded. The perfection 
to which the military drill can be carried is shown by the attain- 
ment of the boys in the industrial school at Glen Mills, whose 
evolutions on the field would do credit to regular soldiers. 

The second means of training is by gymnastic exercises, and 
those in use at Glen Mills are semimilitary and founded on the 
German plan, rather than the Swedish. The boys are lined up 
and marched to the gymnasium, which has a concrete floor. 
Coats, hats, shoes, and stockings are removed, and a brisk drill 
is given either with wands or dumb-bells. This is followed by a 
five-minute period of free play, in which the noise of the boys is 
in marked contrast to the comparative silence of the class work. 
Following this is apparatus work on the parallels, horse, and 
horizontal bar, class leaders being promoted from among the 
boys. After another period of free play the lesson ends by gym- 
nastic games. The boys are then lined up, shoes and stockings are 
put on, and they are marched back to their various occupations. 

The third means of training is by outdoor sports and games, 
in which great freedom of organization and conduct is allowed, 
although strict supervision is still kept and the boys are punished 
for misbehavior by being made to stand along the side line of the 
playground with the back to it for periods of five or ten minutes. 
If the offense is a severe one, the salutory exercise of continuous, 
slow, deep knee-bending is added during their period of punish- 
ment. Competitive games with outside institutions are arranged, 
and track and field sports are freely indulged in, giving good 
opportunities for moral and ethical training, which are not ne- 
glected. The results have been so satisfactory that physical train- 
ing is now established on an equal footing with industrial training 
and school of letters work in the regular days' curriculum of 
these incorrigible boys. 



220 EXERCISE IN EDUCATION AND MEDICINE 

Physical training has a marked effect on the physique, mentality, 
and conduct of criminals who have attained their full growth, 
as proved by the experiments of Hamilton D. Wey, at the Elmira 
State Penitentiary. His description of the criminal is illuminating: 

" The average youthful criminal, as encountered in the prisons 
of the State, is an abnormal production, physically, mentally, and 
morally. Generally under weight, with repulsive features in some 
one or more lines, and asymmetric head; he is coarse in fiber and 
heavy in his movements. His mind, while not diseased, is unde- 
veloped, or it may be abnormally developed in certain directions, 
the smartness resulting therefrom partaking of low cunning and 
centering about self. He is deficient in stability and will power, 
and incapable of prolonged mental effort and application. His 
intellect travels in a rut and fails him in an emergency. His 
moral nature shares in the imperfections of his physical and mental 
state. He does not possess the power to discriminate between 
right and wrong, or if so, it is in favor of himself and avails nothing 
to society. It is easier for him to incline to evil rather than to good, 
to the animal, rather than to the intellectual, and in this he is true 
to himself. His is a perverted moral nature — a blunted mind and 
a crude body." 

It is to physical training that we must look for the awakening 
of those powers that can be directed by firm discipline to the physi- 
cal, mental, and moral betterment of these derelicts. 

During a period of sixteen months a class of 43 dullards was 
given a course of physical training at Elmira. This comprised 
baths at frequent intervals, in conjunction with passive exercise, 
kneading the muscles, working the joints, and general friction by a 
professional trainer; and a manual drill in calisthenics to supple- 
ment the shop work, from which they were excused, although their 
school work was taken as usual. They were put on a specially 
nourishing diet. The physical exercise lasted for about two hours 
a day. They began with the ordinary marching, and in time were 
taught other evolutions, although the teaching of keeping step was 
a matter of weeks. When they could do this well, they were given 
setting-up movements and exercises with dumb-bells up to three 



PHYSICAL EDUCATION OF MENTAL AND MORAL DEFECTIVES 221 

pounds in weight. The lirst experiment lasted from June until 
November, and showed a net average gain of 1.23 pounds a man. 
Various skin diseases disappeared, the muscular condition and the 
carriage impro^'ed, and the response to command became much 
more rapid and accurate. The whole expression of the face im- 
proved, the dull, stolid look assumed a more intelligent expression, 
and the eye gained in brightness and vivacity. 

A mental awakening accompanied this, and their progress 
in school rapidly showed the effects. During the five months 
they were under observation their average marking in school was 
74.16 per cent., as against 45.2 per cent, for five months immediately 
preceding their course of special training. 

This improvement was continued to a remarkable degree, 
and the stimulation of the physical powers in the case of three of 
the class impressed their mental organization to a degree that 
it enabled them to earn their release on parole, whereas if left 
to themselves their minds would never have been so quickened. 

To train these dullard's legs and arms to act with precision and 
in unison was more than the mere rehearsal of mechanical move- 
ments. It was mental as well as physical training, and Dr. Wey 
is of the opinion that in the prisons and reformatories of the country 
" there is a class of youthful felons who can thus be reached in 
their growth period and improved primarily through the training 
of the body, the cultivation of the head following in good time. 
If penal institutions in their educational work could more often 
look upon bodily training as a powerful agent for the physical, 
mental, and moral reformation of their charges, more men would 
be released at the expiration of their time competent to maintain 
themselves honestly." 

This result is only to be obtained by careful physical training 
with an educational purpose, for, as F. H. Nibecker, the super- 
intendent of Glen Mills School, so well ])uls it, " Hard work of 
any particular kind is not complete exercise, nor is it equiva- 
lent to physical training, by which the perception is quickened 
and mental training results, quite as pronounced in effect as from 
efforts that ha\-e mental trainintj more directlv in view." 



PART II 
EXERCISE IN MEDICINE 

CHAPTER XIV 

THE APPLICATION OF EXERCISE TO PATHOLOGIC 
CONDITIONS 

The efficacy of both active and passive exercises in the treat- 
ment of pathologic conditions depends on their power to change 
anatomic structure and to stimulate physiologic function. This 
anatomic and physiologic effect is ^'ery differently expressed in 
exploits of endurance, in feats of strength and skill, and in the 
passive procedures of manipulation and massage. 

Exercises of strength, requiring little coordination, rapidly 
add to the bulk of the muscle tissue, but it is the nervous system 
that receives the accurate training in exercises of skill, while the 
muscle girth is increased but slightly; and mJld automatic exer- 
cises of endurance train the heart and expand the lungs more 
surely than do supreme efforts of strength or the cultivation of 
skilful muscular control. 

Passive exercise has an almost purely mechanical effect on the 
muscle tissue and circulation obtained without the mental concen- 
tration or the taxing of the heart and lungs, required to educate 
or reeducate atrophied and undeveloped coordinations and to 
increase the powers of endurance, and so must be considered 
somewhat as a stimulant by which the nutrition of the part is 
maintained or improved through its blood-supply. 

In a sprained or disabled joint the circulation is subnormal 
and the process of repair is delayed on account of the enforced 
immobility of a structure whose natural function is movement. 
Massage is the most valuable means of hastening recovery in such 
cases, being widely employed by all nations, from the Turks and 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 223 

the Africans to the Siberians and the Laplanders. In an old sprain 
the tissues are matted together; the surface of the skin is dry and 
harsh, bluish, livid, and shrunken in appearance. The stagnant 
blood circulating slowly through the obstructed and narrowed 
vessels is unable to give the tissues sufficient nutrition or to remove 
the accumulated debris of a month's inaction. Manipulation and 
massage act upon the muscles, nerves, blood-vessels, and skin, and 
the circulation at once renews its power. With the application of 
friction and kneading the life of the part is quickened, the veins 
and absorbents are emptied first, and the fluid contained is driven 
on toward the heart; the pressure falls in the smaller vessels and 
tiny irregular lymph-spaces, extending through the tissues in all 
directions. Their contents are driven into the emptied veins, the 
circulation becomes more rapid, metabolism is carried on with 
greater energy, the tissues become full and sensitive to the touch, 
and the parts regain the even, rounded contour of active health. 
The skin loses its harshness, becoming soft and pliable, and after 
a single application the muscles are capable of working with less 
fatigue, while the joints become pliant and the ligaments relaxed. 

In the chapter on Massage it was shown that a muscle ex- 
hausted by lifting a heavy weight does not at once regain its power 
if merely allowed to rest. If it be treated by massage for the same 
length of time, its strength returns, so that it is able to repeat the 
effort with less fatigue. The normal irritability of the muscle 
is temporarily restored, as shown by its sensitiveness to electric 
stimAili. Adhesions are permanently stretched or broken down, 
and the encumbering waste materials thrown into the circulation, 
while the effect upon- the nervous system is indicated by the dis- 
appearance of the pain and sense of insecurity. 

The swelling and tension so characteristic of a recent sprain can 
be quickly absorbed by gentle and careful massage, accompanied 
by elastic pressure and the application of heat between the treat- 
ments. The tension disappears as the fluid is carried off, the 
temperature falls, and the ])ain caused by pressure on the sensory 
nerves is relieved. Extravasated blood is broken up, and the 
adhesions usually found between torn and mangled surfaces are 
prevented, although time is always needed firmly to re])air struc- 



224 EXERCISE IN EDUCATION AND MEDICINE 

tures that have been actually lacerated. In older cases, where the 
synovial membranes have lost their resiliency from long-continued 
distention, where the tissues are sodden and edematous, and the 
effusion dense and firm, massage can be used with greater freedom 
to disperse the chronic congestion and raise the tone of the tissues. 
This improvement is often surprising in its rapidity. The joint 
that has remained for weeks cold and inactive, incapable of per- 
forming its proper movements, the seat of constant wearing pain, 
recovers its flexibility, loses its pain, and allows itself to be handled 
and used with freedom. Manipulating the joint, moving it through- 
out the greatest extent of its normal range, should be added to 
massage in recent cases as well as those of long standing. Few 
minor operations give such instantaneous and striking relief 
when used with care and judgment. These movements stretch 
or snap small adhesions that limit the excursion of the joint or 
press upon nerve-endings, causing acute pain. 

If the sprain be recent, adhesions are prevented altogether, 
but if they have already formed, they may thus be stretched slowly 
and gradually by repeated gentle movements or may be actually 
torn, with instantaneous relief to the patient. It is in these ma- 
nipulations that bone-setters have acquired their reputation for 
supernatural skill, and many miraculous instances are recorded 
of the immediate recovery of long disabled joints. After perfect 
freedom of movement has been obtained, the voluntary power 
is sometimes slow in returning and the recovery must be com- 
pleted by active voluntary exercise in accordance with the natural 
movements of the joint. 

A muscle that is repeatedly exercised in movements of full 
contraction against resistance gradually pulls its origin and inser- 
tion nearer by its inherent elasticity, even when at rest. It is this 
quality of muscular tissue that gives the characteristic semiflexed 
pose to the hand and arm of the weight-lifter or oarsman. It is 
also this quality that is of assistance in the treatment of the many 
faults of posture caused by the overstretching of weakened muscles 
and ligaments, and the consequent overdevelopment and shortening 
of their antagonists. 

The whole struggle of man is to establish and maintain the 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 225 

upright posture by the constant extension of the body, and to do this 
he must overcome the tendency to flexion caused by gravity and oc- 
cupation, for the entire range of postural defects, such as flat-foot, 
round shoulders, flat chest, irregular development, and fatigue scoli- 
osis, are essentially occupation disorders, associated with the mainte- 
nance of the erect position, first, of the muscular system; second, of 
the ligaments; and, finally, in severe cases, of the bones themselves. 
These defects are caused most frequently by long-continued 
faulty positions in the growing child, and it is to the development" 
of the weakened and overstrained muscles, to the stretching of 
contracted ligaments, and to the reeducation of proper sitting and 
standing positions that we must look for the greatest curative 
effects in these disorders. 

Exercises of strength are to be chosen for the correction of 
postural faults, and their selection must be carefully made, for the 
weakened groups must be isolated for action, so that general 
fatigue may not supervene before the full therapeutic effect is 
obtained. 

In certain disorders of the general circulation, with symptoms 
of heart weakness, like breathlessness and oedema, complicated 
by obesity, typical exercises of endurance, such as walking and 
hill-climbing, have been used with success by Oertel and others 
in Sweden, Germany, and America, while the more specialized 
exercises of strength, in the form of simple gymnastics, duplicate 
resisted movements, and the passive manipulations of massage, 
have been used successfully even in cases showing loss of com- 
pensation. 

The treatment of obesity, even when complicated by weakness 
of the circulatory apparatus, requires, in addition to the regulation 
of diet, gymnastic exercises of strength, employing the great 
muscles of the trunk and legs, combined with exercises of endur- 
ance, such as walking and hill-climbing. Massage alone does not 
seem to have much eft'ect in reducing weight. \'on Noorden cites 
the case of a very obese subject whose arm was treated by vigorous 
massage for a prolonged period, without ol^taining any reduction 
in its size. The value of massage, however, is incontestable in 

IS 



226 EXERCISE IN EDUCATION AND MEDICINE 

many disorders of the digestive tract, like chronic and nervous 
gastritis and in constipation, where it can be applied directly over 
the colon throughout its entire course. Its local application to 
rheumatic joints and muscles is a valuable means of treatment in 
certain forms of torticollis, lumbago, and low forms of chronic 
arthritis, but most general disorders of nutrition, like gout and 
diabetes, require exercises of endurance, like walking and riding, 
with the necessary restrictions to prevent overexertion. 

For the myriad derangements and diseases of the nervous 
system exercise in some of its many forms is constantly employed. 
In paralysis massage preserves the nutrition of the muscles and 
prevents contractures by kneading and stretching. Percussion 
and vibration over nerve-trunks act as a counterirritant, and even 
as an anesthetic to relieve the pain of neuralgia, while the head- 
ache of cerebral congestion may frequently be removed by strip- 
ping the great veins of the neck. 

Exercises of skill have had triumphant demonstrations in 
reeducating the impaired coordination of tabetic patients, in 
correcting the incoherent speech of the stammerer, and in quieting 
the disordered movements of the unwilling worshipers of St. Vitus. 

The tonic effect of active exercise on the system has been 
referred to frequently and will be referred to again from time to 
time, but there is one condition where it must be used with the 
greatest caution. 

In anemia the blood is so deficient in oxygen and in red corpuscles 
that even the easier activities of the muscles require an activity of the 
heart out of proportion to the effect. This increased action soon 
reaches its highest possible limit, and- the patient has to sit down, 
breathless and exhausted. Because of this difficulty in supplying a 
sufficient amount of oxygen anemics should be forbidden all exercise 
requiring prolonged or severe exertion, and the tonicity of the 
blood and percentage of hemoglobin must be increased by rest, 
overfeeding, and the administration of iron and arsenic. It is 
only in the form of massage that exercise may be safely applied, and 
then chiefly to prevent the evils arising from overfeeding and rest 
in bed. 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 227 

The increased blood-count found by John K. Mitchell, after 
massage in these cases/ is probably to be explained on the same 
grounds as the experiments of Hawke, described in Chapter II, 
as loosening the blood-cells already in existence, and throwing 
them into the circulation, rather than as an actual increase in 
their number. 

In the treatment of pulmonary tuberculosis the place of 
exercise has been well defined by Kinghorn,- who, after speak- 
ing of the open-air treatment and the treatment by rest, advises 
the patient to begin with walking, at first on level ground, for 
ten or fifteen minutes, every second day for several weeks, then 
every day for several weeks, and at last twice a day. He quotes 
the rule of Brehmer: "The healthy man sits down because 
he is tired; the consumptive should sit down so as not to 
become tired." Patients should be told that all overexertion is 
poison, and that their feelings should be their guides at all times. 
The acceleration of the pulse, perspiration, palpitation, rise of 
temperature, feelings of weakness, discomfort, and headache, 
are all signs that he has overstepped his limit. 

When the patient stands these little walks without harm; when 
the weight increases or holds its own, the exercise may be extended 
under careful supervision, but mountain-climbing should never 
be permitted. 

In cases where no lesion can be found, but where the tendency 
is shown by the history of exposure to infection, by family history,, 
or by the formation of the chest, much good may be expected from 
open-air exercise, accompanied by training of the respiratory 
powers. Deep breathing is a muscular act capable of education, 
and the capacity of the lungs or mobility of the thoracic walls can 
be increased, as well as the strength of any other part of the 
muscular system, while the general circulation, the skin, the 
appetite, and the digestion all share in the heightened activity, 
and healthful sleei) is insured by the resultant moderate fatigue. 

Exercise for this purpose should be general and special. Sing- 
ing and elocution lessons are valuable, and the ])ractice on a wind 

' Soils Cohen, "Physiologic Therapeutics," vol. vii. '-' " Mcmlnal Mi'd. Jour."' 



228 EXERCISE IN EDUCATION AND MEDICINE 

instrument has been recommended. Running and climbing are 
of the greatest value for increasing the breathing capacity if kept 
within the limits of fatigue. All exercises should be prescribed 
in writing, with the most minute directions as to time, frequency, 
and severity, and a record of the patient's weight should be 
kept, and frequent examinations made to determine his progress, 
a loss of weight being followed by a reduction of exercise. 

Daily supervised exercises are necessary to increase rapidly the 
power of chest expansion and vital capacity. They should be directed 
to a training in the best methods of breathing, to the stretching and de- 
veloping of the chest and abdominal walls, and should be preceded and 
followed by accurate measurements and spirometer records. They 
should include both active, duplicate, and passive movements, 
but it must be remembered that, however deep the respiratory 
movement may be, the amount of oxygen absorbed is only in 
proportion to the need of the body. The oxygen in the blood 
remains measurably constant, and the only way to increase its 
absorption by the tissues is to do work that causes the breaking 
down of oxygen compounds. Deep breathing would result 
naturally from more demand, but it would not create this demand. 
Its role will be to strengthen the intrinsic and accessory muscles 
of respiration; to teach the coordination necessary for deep breath- 
ing, and to massage the abdominal contents by wider excursions 
of the diaphragm. 

Deep breathing alone repeated a number of times during the 
day is useful, and its practice should be made part of every day's 
regime. 

The normal respiratory act is a composite of two distinct 
types of breathing — thoracic and abdominal. The thoracic type 
predominates almost to the suppression of the other among all, 
irrespective of sex, who wear constricting clothing about the 
waist-line, and the first care must be to reestablish control of the 
diaphragm and abdominal walls. The following exercises should 
be practised before a mirror: 

Exercise I. — Patient standing. Place the hands across the 
abdomen. Inhale deeply. Exhale by pressing on the abdominal 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 229 

wall, keeping the thorax fixed in the position of inspiration (Fig. 
161). Repeat this movement five times slowly with the thoracic 




Fig. 161. 




Fig. 162. — Inhalation — abdominal. 
The abdomen is protruded without e.x- 
panding the thora.x. 




Fig. 163. — E.xhalation — abdominal. 
The abdomen is indrawn and the breath 
expelled without contracting the chest. 



wall iixed, using the movement of the abdominal walls only. 
Rest. After a little practice this movement should be done with 
the hands at the sides. 



230 EXERCISE IN EDUCATION AND MEDICINE 

Exercise II. — Patient standing. Place the hands across the 
abdomen. Inhale forcibly by pushing out the abdominal walls, 
keeping the thoracic wall fixed as in expiration. Exhale by draw- 
ing in the abdomen. 

Repeat five times slowly. Rest. As soon as control has been 
obtained, practise this exercise with the hands placed behind the 
back (Figs. 162 and 163). 

Exercise III. — Patient stand- 
ing with the hands across the 




Fig. 164. Fig. 165. 

abdomen. Inhale forcibly, using the thorax only, without move- 
ment of the abdominal wall. Repeat five times slowly and rest. 

As soon as control of the abdominal walls has been obtained, 
do this exercise with the hands behind the back (Figs. 166 and 167). 

Thoracic breathing can be forced still further, and the walls of 
the chest stretched by using the arms in the following exercise : 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 23 1 





Fig. 166. — Thoracic breathing — inhala- 



Fig. 167. — Thoracic breathing — exhala- 
tion. The girth of the abdomen remains 
unchanged. 



Exercise IV. — Patient standing with the arms at the sides. 
Raise both arms forward (Fig. 164) until they are above the head, 




Fig. 16.S. 

inhaling. Hold the breath and stretch upward. Rise on ti|)-toes 
(Fig. 165). Lower the arms sideways, j)ressing backward and 
exhaling (Fig. 168). Repeat twenty times at the rate of about 
five to the minute. 



232 



EXERCISE IN EDUCATION AND MEDICINE 



Patients will sometimes have a feeling of dizziness and may- 
even stagger and fall at the sudden change of the blood-pressure 
in the head, but this need cause no alarm. 

Exercise V. — Patient standing with the arms at the sides. 
Raise both arms sideways, pressing back and inhaling (Fig. 169) 

until they are above the head. 
Hold the breath and bend 
forward, keeping the knees 
straight until the hands touch 
the floor (Fig. 170). Rise, 





Fig. 169. 



Fig. 170. 



keeping the arms above the head. Lower the arms sideways, press- 
ing backward and exhaling. 

Repeat twenty times at the rate of five to the minute. 

This exercise compresses the air in the lungs and forces it intO' 
the cells that are little used in ordinary breathing. 

The following duplicate and passive movements may be 
employed for increasing the chest mobility and improving the 
respiration. 

Exercise VI. — The patient lying supine on a plinth, with the 
feet fixed, the arms bent, and the palms up. The surgeon grasps 
the hand, palm to palm (Fig. 171), and pulls upward, to full 
extension of the arms, the patient resisting (Fig. 172). The 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 233 



patient then pulls downward and forward to the first position, 
the surgeon resisting. 




Fig. 171. 


— Artificial respiration. 


Surgeon 


pulling up 


and 


patient resisting. 




^1 


■ 


1 


1 


^^^^^i 




sHII^0 


^^^ 


i5 




^HP^^jgggfj 


LiZ^^^^ 


■^^M^ 


^ 


m 


f 


M m 


^^^^^^■ii^H 




^^^Hl 


■ 


■ 


It 


^1 vj^H 




^^^^^^^^^^H 






H\ 


,^^^H ^*^^^^^H 




HHl 


n 


■ 


■ 


B^^^H 




H^^^'' 






r 





Fig. 172. — Stretching of the thorax by traction on the arms in the movement of arti- 

tk'ial respiration. 

Inhale as the arms go up and exhale as they come down. 
Exercise VII. — The patient lying supine on a plinth, the lower 
part of the thorax sup])ortcd by a roller four inches liigh, the arms 



234 EXERCISE IN EDUCATION AND MEDICINE 

behind the head, and the chest expanded in inhalation. The 
surgeon presses on both sides of the lower thorax, directing the 
patient to exhale (Fig. 173). 

Repeat twenty times at the rate of about ten to the minute. 

A valuable exercise is that given by Zander's machine, known 
as the "tower," in which pressure is placed on the back by a 




Fig- 173- 

cushioned pad and the shoulders are drawn upward and backward 
rhythmically with the respiration. (See Fig. 38, p. 67.) 

Butler, of Brooklyn, has reported many cases of incipient 
phthisis in which deep breathing has been used as an accessory to 
overfeeding and rest, with marked improvement in weight and 
general health; but if the tubercular process is active in the lung, 
deep breathing will only irritate and aggravate what nature 
attempts to splint by limiting the movement o^'er the affected area, 
and in some cases a hemorrhage may be brought on. 

In the application of exercise every attendant condition should be 
made as favorable as possible at all times, to get the best therapeutic 
results. Fresh air should be supplied in abundance, and treatment 
should be given in the open air or a well-ventilated room. Many 
of the disorders of the respiratory tract are due to the impurity, 
rather than to the temperature, of the air breathed. Regularity 



APPLICATION OF EXERCISE TO PATHOLOGIC CONDITIONS 235 

and persistence on the part of the patient are absolutely necessary, 
and the benefit from half an hour's exercise repeated daily is incom- 
parably greater and surer than an equivalent amount taken at 
long, irregular intervals. The necessity of constant individual su- 
pervision is also recognized by all who have had experience in the 
giving of treatment by exercise. Every movement should be 
pushed to its utmost limit of efficiency. Many reported failures 
can be traced to the lack of intelligent personal direction. It is 
not sufficient to give the patient a vague outline of a course and 
leave its carrying out entirely to an assistant, however well trained, 
for in no department of medicine does the personality of the 
surgeon count for more. His presence should be an inspiration 
to his patient, and he should himself insist upon accuracy and 
precision throughout each movement, however simple it may seem 
to the casual observer. 



CHAPTER XV 
FLAT-FOOT AND ITS TREATMENT 

The advantage of the upright position is somewhat offset by 
the frequency of deformities due to a yielding of the structures 
concerned with support. The body may yield at the spine, which 
becomes bent and distorted; at the knee-joints, which knock 
together (genu valgus); or at the arch of the foot, which be- 
comes broken down and flattened, causing the deformity known 
as pes planus, flat-foot, everted foot, or pronated foot. 

The bony structure of the foot is arranged in the form of two 
arches, anteroposterior and lateral. The anteroposterior arch 




Fig. 174. — Anteroposterior arch: i, Short plantar ligament ; 2, long plantar ligament; 

3, plantar fascia. 

(Fig. 174) is formed by the os calcis, the scaphoid, the three 
cuneiform bones, and the metatarsals, with the astragalus as a 
keystone. It is supported by the ligaments extending between 
the adjacent bones like ties, but more especially by the short 
plantar ligament (Fig. 174, i) binding from the os. calcis to the 
navicular. This powerful ligament completes the socket formed 
236 



FLAT-FOOT AND ITS TREATMENT 



237 



by the navicular and the os calcis, into which fits the head of the 
astragalus, or keystone of the arch. The other main ligament 
of support is the long plantar (Fig. 174, 2), which extends from 
the body of the os calcis to the proximal, and indirectly to the 
distal, end of the metatarsal bones, through its connection with 
the tendon-sheaths. These may be termed the first line of de- 
fense in preserving the anteroposterior arch. 

The second line of defense consists in some of the short muscles 
of the foot — the flexor brevis digitorum (Fig. 175, 3) and the 



3 - 




Fig. 175. — The superficial muscles of 
the foot: i, Abductor minimi digiti; 2, alj- 
ductor hallucis; 3, flexor brevis digito- 
rum; 4, tendon of flexor longus hallucis 
(Richer). 




Fig. 176. — Second layer of muscles of 
foot: I, Tendon of flexor longus hallucis; 
2, tendon of peroneus longus; 3, acces- 
sorius; 4, tendon of the flexor longus digi- 
torum and lumbricales; 5, flexor brevis 
minimi digiti (Richer). 



flexor brevis hallucis (Fig. 177, 3) — assisted by the tendons of 
the flexor longus hallucis (Fig. 175, 4), the flexor longus digi- 
torum (Fig. 176, 4), and of the tibialis posticus, passing around 
the inner malleolus, and binding together by its expanded tendon 
all the bones of the tarsus except the astragalus. The til^ialis 
anticus (Fig. 178, 1) also helps ])y lifting the proximal end of 
the first metatarsal bone. These muscles, by tlieir action, all 
tend to lift the inner side of the foot and draw together the limbs 
of the anteroposterior arch, like the string of a bow. 



238 



EXERCISE IN EDUCATION AND MEDICINE 



The lateral arch of the foot (Fig. 1 79) is imperfect, in that its 
support is at the outer side only, the weight being borne by the 




Fig. 177 . — Deep layer of muscles of the 
foot: I, Peroneus longus; 2, interossei; 3, 
flexor brevis hallucis; 4, 5, adductor hal- 
lucis (Richer). 




Fig. 17 8 . — The tendons that support the 
arch: i, Tibialis anticus passing under an- 
nular ligament (2); 3, soleus; 4, flexoi' 
longus digitorum; 5, tibialis posticus; 6j 
flexor longus hallucis; 7, tendo Achilles; 
8, abductor hallucis (Richer). 




OS calcis, the cuboid, and the fifth metatarsal. The arch rises 
upward and inward, and its free, unsupported edge is represented 
by the astragalus, the navicular, the internal 
\ cuneiform, and the iirst metatarsal. The 

lateral arch is supported principally by the 
tendon of the peroneus longus (Figs. 177, i; 
176, 2), crossing the foot diagonally from 
the cuboid to the internal cuneiform, and by 
the ligaments binding together the adjacent 
bones; it also receives some support from the 
tibialis anticus. 

The body weight is transmitted through the tibia to the astraga- 
lus. This pressure on the keystone tends to spread the mehibers 
of the arch, and, in so doing, to stretch the long and' short plantar 
ligaments. As the structures yield the inner side of the foot comes 
down, and the lateral arch shares in the flattening process. It is, 



Fig. 179. — Lateral 
arch. Pull of pero- 
neus longus. 



FLAT-FOOT AND ITS TREATMENT 



239 



however, the unsupported part of the arch that is chiefly affected, 
and the flattened instep also projects inward, causing the inner 
hne of the foot to bulge at its center, the outline becoming convex 
instead of straight or concave. Pressure is thus put on surfaces 
of the bone that are not accustomed to it, and severe crippling 
pain is one of the most common results, while corns and callosities 





Fig. 180. — Direction of the body weight 
on the unsupported part of the lateral 
arch. 



Fig. iSi. — Transferring the direction of 
the body weight to the outer side, or sup- 
ported part of the arch, by raising the 
inner side of the shoe. 



add their discomfort to the unnatural pressure and friction of 
the abnormal position. 

A typical case of flat-foot would then show a turning-out of 
the line of the heel, a convexity of the inner contour of the foot, 
and a concavity of its outer margin. A tracing of the foot would 
show no instep (Fig. 183). While this deformity is sometimes 
caused by paralysis of the posterior tibial group of muscles, or ]jy 
the peroneal group, and is also the result of traumatism in 1)road 



240 



EXERCISE IN EDUCATION AND MEDICINE 



jumpers, whose arch is broken down by the shock of landing on 

hard ground, still the great majority of cases are what might be 

termed static, and are found in 
nurses, clerks, waiters, barbers, 
motormen, and all others whose 
long hours of continual standing 
keep the muscles and ligaments 
of the foot constantly upon the 
strain. It is also frequently found 
in the very fat, whose excessive 
weight is too much for their liga- 
ments. 

It is a comparatively frequent 
condition, and is usually asso- 
ciated with other deformities of the 
apparatus concerned in support. 
Bernard Roth', in his series of 
1000 cases of scoliosis, found it 
in 76 per cent, of them. In an 
examination of 1000 supposedly 
normal students I have found 
it in 217 cases. Among men 

applying for military service in the United States, about 3.4 per 

cent, are rejected for this cause. These figures, however, do not 

include men who are suffering from 

fiat-foot, but who are rejected for 

some major trouble. An applicant 

suffering from hernia and fiat- 
foot would be rejected, but the 

cause of his rejection would be 

given as hernia. Lovett has found 

many cases among hospital nurses, 

who are peculiarly susceptible to 

it. 

The symptoms are very varied. A considerable degree of 

flat-foot may be present without causing much irritation, and 




Fig. 182. — Flat-foot (Fowler). 



f'< 



irN' 



^ 



\r 



L 



\ 



Fig. 183. — Print of a normal 
foot-sole (a) and of a fiat-foot sole 
(B) (Albert). 



FLAT-FOOT AND ITS TREATMENT 



241 




again great pain may be caused l^y comparatively slight degree. 
Painful points are found at the calcaneonavicular ligament, the 
anterior end of the os calcis, at the 
attachment of the short plantar liga- 
ment, and at the base of the first 
metatarsal, while there may be shoot- 
ing pains up the calf of the leg. 
The heels, as seen from the back, 
are characteristic, the line of the 
tendo Achilles, with the ball of the 
heel, usually making a sharp turn 
outward (Fig. 184). This is em- 
phasized when the weight is borne 
on the foot. It may very often be 
detected by examining the shoe only, 
the flat-footed patient tending to 
wear down the inner side of the 
heel and sole. 

A patient should be examined 
with the foot uncovered, walking 
backward and forward in order 
that the foot may be seen in action 

from all positions. The inner line of the foot, and the extent to 
which the instep is destroyed, should be noted. 

Cases are best recorded by making a print of the weight-bearing 
foot as follows: Prepare a solution of perchlorid of iron in glycerin. 
By means of a brush or cotton- wool wrapped on a small stick 
paint the sole of the foot with this solution, place the patient's foot 
on a sheet of paper, having him put the full weight down upon 
it. Brush the resulting print with a solution of tannic acid, and 
the tracing becomes black and legible, and forms a con\'enient 
means of following the progress of treatment. 

^he appearance of the foot is not the only thing to Ije considered, 
for the arch of a baby's foot has an appearance of flatness, because 
the pad of fat which occupies the arch is not absorbed until the 
child has begun to walk. 
16 



Fig. 184. — Showing one of the 
first signs of flat-foot. The out- 
ward deflection of the lower end of 
the tendo Achilles when weight is 
put on the foot (E. H. Ochsner). 



242 EXERCISE IN EDUCATION AND MEDICINE 

Flat-foot is liable to be confused with tenosynovitis, the pains 
from corns and callosities, and with neuralgia of the metatarsus or 
the tendo Achilles. The most frequent mistake in diagnosis is 
rheumatism, which seldom affects the foot alone, although I have 
seen it in one case in which the diagnosis of rheumatism was 
confirmed by its subsequent appearance in other joints. 

Although not a fatal disease, it is the cause of great pain and 
discomfort, and sometimes the patient becomes chair or bedridden. 

Treatment must both support the arch and correct the de- 
formity, so that no treatment is complete which does not develop 
the structures involved in the normal preservation of the arch. 

The market is flooded with patent devices for the support of 
the broken-down arch, but no mechanical treatment should be 
employed unless it accurately fits the particular case. More harm 
than good has been done by the use of ill-fitting and imperfectly 
supporting foot-plates. A foot-plate or bandage of any kind 
must be looked upon in the light of a splint, to be discontinued as 
soon as possible, and to be used only in conjunction with other 
means of treatment. 

In most cases treatment by exercise should be begun by ma- 
nipulation, stretching, and massaging the foot; but where the 
pain is too severe, it may be necessary to give the foot a complete 
rest for two weeks or more by incasing it in a plaster bandage. 
When tenderness is sufficiently lessened, the following manipula- 
tions and active exercises may be started: 

Exercise I. — Patient sitting, leg extended and supported just 
above the ankle. Grasp the right foot just above the ankle with 
the left hand. Place the right hand on the sole of the foot. With 
the thumb pointing toward the toes grasp the foot firmly, circum- 
duct the foot slowly in the following order: (i) Extension; (2) 
inversion; (3) flexion; (4) eversion. 

This should be done with as much force as can be used without 
producing pain, and repeated up to about thirty times. Each 
part of the movement should be separated from the next by a 
distinct pause. When this has been learned, it may be replaced 
by the active movement. 



FLAT-FOOT AND ITS TREATMENT 



H3 




FiiT. i86. — Inversion of the foot. 




Fif^. 187. — Flexion of tlit- foot. 



Exercise II. — Foot in the same jjosition. Circumduc ion in 
the same order without assistance. Repeat fifty times. 



244 



EXERCISE IN EDUCATION AND MEDICINE 



The operator should supervise this movement and encourage 
the patient to make the extension and inversion as complete as 




Fig. 1 88. — E version of the foot. 

possible, so that the long and short flexors and tibial muscles may 
have complete contractions at each movement (Figs. 185-188). 



M^ 
'i 





Fig. 189. Fig. 190. 

Exercise III. — Patient standing with toes in and heels out, 
and about twelve inches apart (Fig. 189). Rise on the toes and 
press out slowly (Fig. 190). Repeat fifty times. 



FLAT-FOOT AND ITS TREATMENT 



24s 



Exercise IV. — Patient standing, feet parallel and six inches 
apart. Raise the inner side of the foot, throwing the weight on 
the outer border. Repeat fifty times. 

This transfers the weight from the ligamentous support to 
the bony ridge of the outer edge of the foot (see Figs. 180 and 181) 
and should be followed by — 

Exercise V. — Patient standing, feet 
parallel, weight resting on the outer side 
of the foot (Fig. 191). Walk forward and 
backward fifty steps, keeping the feet 
parallel. 

This exercise is also valuable in throw- 
ing the weight of the body on the solid 
part of the lateral arch, and is one that is 
often instinctively taken by patients to re- 
lieve the intolerable pain caused by the 
overstretching of the ligaments. 

Exercise VI. — Raise the heel one inch 
from the ground and walk without bring- 
ing the heel dow^n at all, as if the heel 
were painful. 

This exercise may be practised indefi- 
nitely, the patient walking for 100 yards 

without letting down the right heel, and then the next 100 yards 
without letting down the left, or raising the heels when crossing 
the street, or other plans that will readily suggest themselves. 
A little practice will enable him to walk in this way without limp- 
ing or otherwise attracting attention. 

These exercises should Ijc repeated daily, and in slight cases 
should be carried on for at least three months, whereas in severe 
cases it should be kept up as a daily routine for at least one year. 
In favorable cases this may be all that is required (Figs. 192-195), 
but usually it will have to be comljined with some form of 
specially designed shoe, with strapping or other mechanical sup- 
port to retain the gain and to prevent the original cause of the 
deformitv from imdoinir tine correcti\'e work of tlie exercises. 




]-"ig. 191. — Walking on the 
oilier sides of the feet. 



246 



EXERCISE IN EDUCATION AND MEDICINE 



The shoe should present a straight inner line, allowing perfect 
freedom to the toes, and high heels should be avoided. An 





Fig. 192. — M. March 6 





Fig. 103. — M. April 3. After one month's exercise only. 

excellent shoe has been devised by Small, of Boston, in which the 
rigid shank from the heel to the sole of the shoe is replaced by one 
that is flexible, allowing: free movement to the whole foot and vet 



FLAT-FOOT AND ITS TREATMENT 



247 



giving adequate support. The inner side of the heel and sole may 
be thickened, or a cork insole may be made to lift the inner side 





Fig. 194. — -A.M. November 4. Before 
Vjeginning treatment. 



Fig. 195. — \. M. March 10. After 
e.xercise treatment for five months. 



of the foot. This places the thrust of the body weight outward 
toward the supported side of the foot-arch, and lessens the strain 
on the ligaments. 




Fig. 196. — Whitman's i)lalc to su[)f)ort llu- arc h of llio foot in flat-foot (Fowler). 

Among the many plates designed for the foot, undoubtedly 
the best is the one described l)y Royal Whitman (Fig. ig6). A 



248 



EXERCISE IN EDUCATION AND MEDICINE 



plaster cast of the foot is taken, and an iron plate is fitted to it, 
with bearing points at the head of the first metatarsal, under the 
heel, and behind the fifth metatarsal bone. From these bearing 
points the plate fits into the arch of the instep, and may be trimmed 
to suit the convenience of the wearer. It is easily removable from 
the shoe, and does not press upon the foot except when it is bearing 
the body weight. 

A bandage which has proved exceedingly useful in the hands 
of Ochsner is described by him as follows: 

" I first select a good make of zinc oxid adhesive plaster in 
1 2-inch rolls After measuring the patient's leg I mark off the 
adhesive strips according to the size of the extremity. For the 
purpose of strapping a male patient of ordinary size I mark off 

















/s. >c .^:i -^ 








j'/yx /3 


J'/yx/^ 


■ i'^x// 


J'^/Mf 


3'4' X i' 


3'6'xf 


j'/yxS 




.. 






,, 


'/iy f 


'A y / 


'Ax f 


Vj XJ,' 











Fig. 197. — Showing how the zinc oxid plaster is marked off preparatory to cutting strips 
for strapping an adult male patient's foot (E. H. Ochsner). 

7 strips J inch wide by 32 inches long, with a cross line at its 
middle; 16 strips J inch wide and 18 inches long; i piece t,j inches 
by 13 inches; i piece 3^ inches by 12 inches; i piece 3! by 11; and 
4 pieces 3^ inches by 8 (Fig. 197). I do this as a matter of 
convenience, and in order to prevent the unnecessary handling of 
adhesive plaster after the facing is once removed. 

The heel of the patient's foot is now placed on the chair, with 
the knee flexed, and a short, hard, roller bandage is looped around 
the foot. I direct the patient to draw the foot upward, thus placing 
the foot at a little less than a right angle to the leg, moderately 
inverted and adducted, the patient holding the bandage himself. 

I now put the middle of the 32X2 inch strip ov^r the bottom of 
the heel, about one inch from its posterior border, one half up the 



FLAT-FOOT AND ITS TREATMENT 



249 




outer surface of the leg, without tension, and the other up the 
inner surface of the leg, as tight as I can. I then place one of the 
shorter narrow strips on the inner surface of the foot, parallel with 
the sole, and on the outer surface. The remaining narrow strips 
arc placed in the same manner, 
each one slightly overlapping its 
predecessor. When these are all 
in place, I cover them with the 
7 remaining strips, beginning at 
the upper part of the leg, as illus- 
trated in Fig. 198. These strips 
will remain in place and be ef- 
fective from four to eight weeks, 
when they may be removed with 
benzin. The foot is washed with 
soap and warm water, carefully 
dried, and it is again restrapped 
the following day. A foot may 
require from two to ten strappings, 
and the relief is almost immedi- 
ate. This strapping tends to supinate the foot and relieve the 
pain by relaxing the muscles and supporting the ligaments." 

I have quoted this at length, because the best results can be 
obtained by a combination of this treatment with exercise. From 
the perishable character of the plaster, one is less apt to depend 
upon it alone, as is so frequently done with the metal flat-foot 
supports, while the danger of injury to the foot from bruising and 
formation of callositi'es arising from the use of plates unskilfully 
applied is completely avoided. 

A flat-foot plate or bandage must, as already emphasized, be 
regarded in the same light as a crutch or cane would be for a 
joint unaljle to bear the strain of use, and it is to Ijc discarded 
when the normal strength has returned and undue irritability has 
disappeared. 

To continue the supj)ort after the in(h'cations for its use have 
disappeared is to hamper the normal functioning of the muscles 
and ligaments of the foot and le<i. 



Fig. 19S. — Showing arrangement of 
the 3j-inch strips over the narrower 
strips (E. H. Ochsner). 



CHAPTER XVI 

THE CAUSE AND TREATMENT OF ROUND BACK, 
STOOPED, AND UNEVEN SHOULDERS 

If an infant be placed upon its back, it will lie with a straight 
spine and thighs flexed to nearly 90 degrees. If it be placed in a 
sitting posture, the thighs remain flexed, but the spine shows a 
single convex backward curve, involving its entire length, but 
with the assumption of the standing posture, the right angle be- 
tween the trunk and thighs must be extended to a straight line, 
and this is effected by a compromise between the lumbar spine 
and the hip-joint, both yielding part of the way. 

When the hip-joint is extended, the iliopsoas muscle is 
stretched, though this extension is not sufl&cient to preserve the 
straight spine of the sitting posture. A sharp, forward curve de- 
velops in the lumbar region. The anterior vertebral ligaments 
are stretched, the intervertebral discs thicken anteriorly, and the 
erector spinas muscle becomes active and powerful. This curve, 
which is very marked in young children, gives them their char- 
acteristic "pot-bellied" appearance, and is accompanied by a 
localization of the compensating backward curve to the dorsal 
region, and by the formation of a third in the cervical region, 
showing the same forward convexity as the lumbar curve. These 
three curves are physiologic, and are always found in the adult 
normal spine, and it is their exaggeration or imperfect develop- 
ment that will be considered in this chapter. 

The shoulder-girdle is constructed to permit the widest range 
of movement with the utmost lightness of structure, but the 
pelvic girdle, whose chief ofi&ce is that of support, is firm and 
arch-like, with powerful ligaments, heavy bones, and scarcely 
perceptible movement, while the entire weight of the head, neck, 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 25 1 

upper extremities, and shoulders hangs upon the flexible and grow- 
ing spine during the standing and sitting positions, and the mus- 
cles that steady the spinal column rapidly become fatigued when 
thus kept on the strain, and allow the shoulders to droop forward, 
bending the neck and back with them. The resulting deformity 
is called stoop shoulders, slant shoulders, round back, faulty atti- 
tude, kyphosis, or bowed back, and when the deviation is to the 
side, either right or left, it is known as scoliosis or lateral curvature. 

The condition of round shoulders can be determined only 
after the normal standing attitude is clearly defined in the mind, 
and deviations from this normal attitude can then be noted and 
accurately described. Anteroposterior deformities may be classi- 
fied as round back, round hollow back, and forward displacement 
of the shoulders (Lovett). 

In the normal standing position a plumb-line will touch the 
sacrum and the dorsal spine at its greatest projection. This, 
however, does not give the attitude of the head, which is most 
important. This can be obtained by taking an upright rod, such 
as is used for measuring the height. On this is a sliding horizontal 
arm at right angles to it. On this arm, six inches from the back 
surface of the upright rod, another horizontal rod is attached, 
eighteen inches in length, and extending at right angles to the arm 
The back surface of the upright rod is taken as the perpendicular 
plane from which distances are to be noted, and the measurements 
are made from the second horizontal rod, which is always six 
inches away from the plane of the upright. Any point more than 
six inches from the sliding horizontal arm is in front of the per- 
pendicular plane agreed on, and any point less than six inches is 
behind it. To obtain the measurements, the following points are 
marked with a flesh-pencil: (i) The external malleolus; (2) the 
head of the fibula; (3) the great trochanter; (4) the fourth 
lumbar spine; (5) the seventh dorsal spine; (6) the si)ine of the 
vertebra prominens; and (7) the middle of the mastoid process. 
These points having been marked, the patient stands with the 
malleolus opposite the upright, and each of these ])oints from tlie 
horizontal arm is rapidly noted from abo\-e downward. The 



252 



EXERCISE IN EDUCATION AND MEDICINE 



height of each of these points is then noted, and from this data the 
posture can be graphically shown. 

A composite of 72 normal boys (Greenwood) between the ages 
of fifteen and nineteen years shows the following tracing (Fig. 200). 




/ 



6%] 



Fig. 199. — Lovett's apparatus for 
measuring variations from normal atti- 
tude in the anteroposterior plane. 



Fig. 200. — Com- 
posite curve of 
seventy-two nor- 
mal boys (Green- 
wood). 



Fig. 201. — Curve of 
young adult female of 
good carriage (Lovett). 



By means of this standard we are enabled to divide faulty 
attitudes into — (i) Round back, showing a general curve back- 
ward, with little lordosis. (2) Round hollow back, with the 
backward projection greatest in the middorsal region, and with 
pronounced lordosis, the forward projection of the head bringing 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 



■bo 



the upper three measurements ahnost in line. (3) Forward 
displacement of the shoulders, the scapula? and clavicles being 
displaced independently of the condition of the spine. This 
condition may exist either with or without a rounded back. 
A graphic tracing of these curves may also be obtained by 

the pantograph method de- 
scribed in the following 
chapter. 

From the standpoint of 
treatment these deformities 
may be classified into flexi- 
ble and resistant. 




Fig. 2o;j. — ^Making a tracing of the antero- 
posterior curves of the spine by the pantograph 
method. 



Fig. 203. — Anteroposterior trac- 
ings of the spine: a, Correct posture; 
b, first type of round back ; c, ex- 
treme resistant round l)ack in a 
young girl. 



During the years of growth j;osture will usually take care of 
itself if constant change be allowed, for change is instinctive and 
automatic in the child, and his ^■aried activities may be trusted 
to lead him along normal lines. If, from inherent weakness or 
the confinement of school life without the relief of games and 



254 EXERCISE IN EDUCATION AND MEDICINE 

play, this normal development be hindered, the spine is one of the 
first parts of the anatomy to reveal it. 

The causes of round shoulders are, then, those general con- 
ditions that produce muscular or constitutional weakness, like rapid 
growth, overwork, bad air in schools or home, acute illness, myopia 
uncorrected by glasses, poor hygiene at home, or general lack of 
exercise, and, secondly, occupations that demand long-continued 
flexion during the period of growth. Among these may be men- 
tioned the use of ill-fitting school furniture, long-continued writing 
and drafting or ^^•ork with the microscope; in fact, the requirement 
of any fixed position for more than a few minutes at a time in a 
young child. His restlessness in school is his only means of 
protest, and is the object of much misapplied correction by those 
school-teachers who believe that quietness and goodness are 
synonymous. The third cause, more direct than either of the 
others, is the wearing of clothing supported by suspenders bear- 
ing on the points of the shoulders, tending to pull them downward 
and forward or even to produce a painful deformity of the scapula. 

An examination of the back should begin by testing the spine's 
range of movement, forward, backward, and lateral. The patient 
should then take his habitual standing position, which he should 
retain until his self-consciousness abates. The overcorrected 
standing posture should then be tried. This may be done by 
having him force the chest forward and upward to touch the 
surgeon's hand, held just far enough in front of and parallel to 
the chest-wall to bring the contour of the thorax directly above 
that of the abdomen. This maneuver should always be done 
before a mirror, that the patient may associate the sensation with 
the picture of the correct posture, and it will take time and 
patience on the part of both. He should then be taught to take 
several long breaths without relaxing the pose. If the child be 
placed face downward, with the arms at right angles to the body, 
flexibility of the shoulders can be tested by attempting to force 
them back of the middle line of the body. They should then be 
lifted upward beside the head and forced backward. During 
these movements the whole spine should be narrowly observed, 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 255 



as in resistant cases the arms cannot be brought behind or even 
up to the median plane of the body. It can only be simulated 
by hollowing the lower part of the back and protruding the abdo- 
men, flattening the chest, and projecting the chin. In non-resistant 
cases there is usually a general relaxation of the ligaments, as shown 
in hyperextension of the elbows 
and knees, as well as of the 
spinal ligaments, and if the 
patient can voluntarily assume 
a correct position, the case 
may be pronounced non-resist- 
ant. In resistant round shoul- 
ders and forward displace- 
ment, however, there is al- 
ways more or less structural 
change, involving a forward 
curvature of the upper part of 
the scapula, a shortening of 
the coraco-acromial ligament, 
or, according to Fitz, a tight- 
ness of the serratus magnus 
muscles, associated wnth weak- 
ness of the rhomboids and 
trapezius. 

It is a very frec{uent de- 
formity among school-children, 
and it occurs in almost 20 per 
cent, of university students 
uncomplicated with other pos- 
tural defects. Where a greater 

deviation is present, such as lateral curvature, a note is usually 
made of the scoliosis only, so that its occurrence is more fre- 
quent than these ilgures would indicate. 

It is frequently discovered in girls about the age of ])uberty, 
when especial attention is apt to be paid to their figure and car- 
riage. 




Fig. 204. — Showing a common under- 
waist with the straps bearing upon the 
outer part or movable part of the shoulders 
(Goldthwait). 



256 



EXERCISE IN EDUCATION AND MEDICINE 



Round shoulders are not likely to be outgrown, and patients 
usually become permanently and structurally set in the faulty 
position, with flattened chest-walls and distorted figure. 

By adequate treatment all cases are capable of improvement, 
and almost all, except the most resistant, are capable of complete 
cure. Before beginning treatment it is important to differentiate 
between the flexible and the resistant cases and between both and 
arthritis, where pain is usually a prominent symptom. An irri- 
tated spine must also be excluded, as well as the early stage of 





Fig. 205. — Correct support of clothing. The weight comes on the root of the neck 
instead of. the shoulder tips (Goldthwait). 



Pott's disease, so that any case of sore spine before being treated 
by exercise should undergo a rigid examination, and be kept for 
some time under careful observation. 

Treatment may be divided into — (i) Hygienic; (2) exercise; 
(3) stretching. 

(i) Hygienic. — The patient should have the best available 
surroundings as to light, air, and food, because, as a rule, they are 
underdeveloped muscularly and have not the constitutional 
resistance nor the will-power of the average child. The muscle 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 257 

fatigue that comes on from the strained, fixed positions among 
school-children must be avoided by every available means. School 
furniture should be adjusted to prevent undue flexion of the back 
and forward bending of the head during reading and writing. 
Errors of refraction should be corrected. The clothing should be 
examined, and when found to be supported from the tip of the 
shoulders, the garments should be altered to bring the pressure in 
toward the root of the neck, instead of out on the shoulders. 





Fig. 206. — Correct standing posture. 



Fiif. 20: 



-Incorrect standing posture. 



(2) Exercise. — In the treatment by exercise, expansion of the 
lungs by deep breathing to round out the flattened chest should 
be emphasized. These exercises have been described in Chapter 
XI\\ The correct standing position and carriage of the body 
should be continually and persistently insisted upon. This 
must not be done by contracting the retractors of the shoulders, 
but rather by bringing in the chin and forcing the thorax forward 
and upward (Fig. 206), as already described. The muscles of the 
17 



258 



EXERCISE IN EDUCATION AND MEDICINE 



upper back must be strengthened to carry out their function of sup- 
port, and the abdominal muscles must be developed and trained 
to overcome the weak and relaxed carriage of the protuberant 
belly. The following exercises would constitute a daily prescrip- 
tion: 

Exercise I. — Patient standing in his habitual faulty position 
(Fig. 208) . Place the hand about one inch in front of the sternum, 
and tell him to raise the chest and shove it forward to touch the 




Fig. 208. — Diagram showing the rela- 
tion of the head, thorax, and pelvis in the 
incorrect standing position. 



- Fig. 209. — Diagram showing the rela- 
tion of the head, thorax, and pelvis in the 
correct standing position. 



hand without swaying the body. In doing this at first he will try 
to draw the shoulders back, contracting the trapezius and rhom- 
boids. This fault must be overcome at the very beginning, and 
the shoulder muscles must be kept relaxed. Gradually increase the 
distance to which he can bring the chest forward, repeating it 
again and again until he can take the position without difficulty 
and without contracting the muscles of the back. While in this 
position make him breathe deeply five times and then relax. This 
should be done before a mirror, so that he will recognize the 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 259 

feeling of the correct posture and associate it with the proper 
attitude, as seen in the glass. He should then try to take it without 
looking at the mirror. This posture should be drilled into him 
until it becomes habitual, and until he can maintain it without 
discom.fort. 

R. J. Roberts, of Boston, is accustomed to tell his young men 
to press the back of their neck against their collar-button, con- 
sidering this as the keynote of the position. In whatever way it 





is accomplished, the object is to get the ])roj>er relation Ijetwecn 
the thorax and the jiclvis. 

After repeating Exercise i twenty times take Exercise 2. 

Exercise II. — Arms forward raise, u])ward stretch, rise on 
tip-toe, inhale. Sideways lower, slowly press the arms back. 
Exhale (Figs. 164, 165-168). 

This exercise, when done correctly, expands the chest, bringing 
in all the extensors of the back and the levators of the shoulders. 



26o EXERCISE IN EDUCATION AND MEDICINE 

Exercise III. — Patient standing, arms down and back, fingers 
interlocked and palms outward (Fig. 210). Extend the neck, roll 
the shoulders back and forearms into supination, the palms being 
first in, then down, and then out (Fig. 211). Reverse to starting 
position and relax. 

This exercise is particularly valuable for projecting the chest 
forward, stretching the shortened ligaments, and drawing in the 
abdomen. Care should be taken to have the chin pressed back- 
ward when the arms are brought downward and turned outward. 
In resistant cases, where this exercise cannot be done with the 
fingers interlocked, a handkerchief tied in a loop may be sub- 
stituted and held in the fingers. (See Fig. 270.) 




Fie 



Exercise IV. — Patient standing with the arms at the sides. 
Arms sideways, raise, upward stretch, inhale, forward bend, and 
rise. Arms sideways lower. Exhale. (See Figs. 169 and 170.) 

In this exercise the lungs are filled when the chest is in the most 
favorable position for expansion. The breath is retained when 
the trunk is flexed, forcing the air into the cells of the lungs under 
pressure. The bending and rising bring into powerful action the 
extensors of the back and neck and the retractors of the shoulders. 

Exercise V. — Patient lying prone upon a couch with the feet 
strapped or fixed by an assistant. Hands clasped behind the 
head. Raise the head and extend the spine, pressing the elbows 
backward (Fig. 212). Relax. 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 261 

This exercise is a severe one on the extensors of the back and 
the retractors of the shoulders. 

Exercise VI. — Patient lying in a prone position, arms at the 
sides. Raise the head (Fig. 214), bringing the arms forward 
(Fig. 215). Imitate the breast stroke in swimming (Fig. 216). 




Fig. 213. — Deep breathing exercises introduced between two extension movements. 

In this exercise the erector spinas is kept in static contraction, 
while the retractors of the shoulder are alternately contracted and 
relaxed. 






Fig. 214. 

Stretching exercises that require the services of an assistant 
or a machine designed for the purpose should be associated with 
these voluntary movements. Sylvester's method of artificial 
respiration (Figs. 171 and 172) may be employed with good effect, 
the upper dorsal region being supported by a hard j)illow, tlic 



262 



EXERCISE IN EDUCATION AND MEDICINE 



surgeon pulling at the end of the upper movement, stretching 
the thorax to its utmost. The intercostal machine (Fig. 217) is 
invaluable for securing the same kind of movement. Zander's 
machine, the " tower" (Fig. 38, p. 67) , straps the shoulder backward 




Fig. 215. 

and forces forward the rest of the body, imitating closely the 
movement and rhythm of ordinary respiration. The quarter-cir- 
cle (Fig. 29, p. 60) is another gymnastic machine designed to give 
breathing exercises, with the body held in an overcorrected 




Fig. 216. 

position. Taylor's "spinal assistant" (Fig. 218) produces the 
same effect by suspending the weight from the arms with ac- 
cented pressure on the dorsal region, either from behind, forward, 
or laterally, as shown in the illustration. 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 263 

G. W. Fitz, as a result of an exhaustive investigation, came 
to the conclusion that the pectoral muscles were not guilty of 
causing round shoulders, as had been previously supposed, and 
condemns those stretching movements in which the body-weight 
is carried by the hands as having but little effect on the serratus 
magnus, which he considers to be the muscle chiefly at fault. 




Fig. 217. — Triplicate chest weight, overhead or intercostal attachment. 



The main value of these stretching movements is, however, on 
the ligaments, rather than on the muscles. 

In slight cases of round shoulders the strapping described by 
Goldthwait, to draw the shoulders backward, is of real value. 
It is composed of firm webbing, one inch wide, carried as a loop 
around each shoulder, the bands crossing in the back and being 
attached to the belt of an ordinary stocking supporter. The 
attachment of the shoulder strap to the belt should be at the side, 



264 



EXERCISE IN EDUCATION AND MEDICINE 



directly over the stocking straps, and the belt should be worn about 
the hips and not about the waist, as is usual. The straps should 
be sewed where they cross at the back, over the angles of the 
scapulae, but should not be sewed where they cross in the mid- 
line. This allows body movements, both to the side and forward, 
without straining upon the straps or changing the position of the 
belt level. 




Fig. 218. — Taylor's spinal assistant for suspension and lateral pressure 



For more resistant cases, where very active stretching is 
necessary, Lovett's apparatus is the best. It consists of an oblong 
gas-pipe frame. Hinged to this, near the middle, is another 
section of gas-pipe of the same shape and size as the upper half of 
the frame. To this movable section is fastened at right angles a 
gas-pipe bridge rising about eighteen inches above it and movable 
on it (Fig. 219). When prepared for use, two strips of webbing 
lying one over the other run from each of the two buckles at the 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 265 

bottom end of the frame. The lower pair are tightly drawn and 
run through buckles at the upper end of the movable section. 
The upper two are loosely fastened to the bridge. The patient 
is laid face downward on the webbing strips, protected by a piece 
of sheet-wadding if uncomfortable. The thighs are flexed and 




Fig 219. — Apparatus for stretching round shoulders (modified from Lovett). 



the feet rest on the floor, so that the lumbar spine is flattened. 
Two pieces of webbing are placed over the middorsal region from 
side to side, tied to the lower non-movable frame on each side, 
thus furnishing the resistance for the straightening of the spine 
when the upper end of the movable frame is raised, carrying with 



266 EXERCISE IN EDUCATION AND MEDICINE 

it the head and upper chest. After the patient is in place, the 
upper part of the frame is hfted, the amount of force permissible 
being not beyond the point of mild discomfort. Several stretchings 
are made of a few seconds each, the movable part of the frame being 
let down to rest the patient. 

Flexible round shoulders in most cases yield to exercise alone, 
extending over a period of three to six months of daily treatment, 
but it may be advisable to maintain the improvement for a time 
by means of some such simple brace as the one described by 
Goldthwait, although fixation without exercise is irrational and 
leaves the condition worse than it found it. Some resistant cases 
will require stretching by the Lovett apparatus and fixation in 
the corrected position, combined with vigorous development of 
the muscles of the back and prolonged training in the corrected 
standing position. 

Occasional cases in which there is structural deformity have 
been treated by cutting the coraco-acromial ligament, or an 
operation on the deformed scapulae, as described by Goldthwait, 
but such cases are the exception and need not enter into the 
discussion. 

After active treatment has ceased, the patient should be kept 
under supervision, reporting progress at least once a month for 
two years. 

It is the rule, rather than the exception, to find associated with 
round shoulders some inequality in their height. In looo con- 
secutive examinations of supposedly normal young men, the right 
shoulder was low in 140 cases and the left low in 20 cases, and 
tailors tell me that it is almost the rule to put extra padding in 
the right shoulder of coats for the sake of appearance. 

The causes of an irregularity A'arying from three-fourths to 
two inches are sometimes difficult to disentangle, but the carrying 
of weights, like school-books, and bad habits in sitting and stand- 
ing are among the most potent. The position of the child sitting 
at the school desk during writing favors it, since the left arm and 
shoulder are supported and the right lowered. Habitual standing 
with the weight on the right leg contributes to a good many cases, 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 267 



as will be seen in the descrij^tion of scoliosis, but weights carried 
in the hand or pressure on the right shoulder are the most direct, 
and it is a common thing to see this deformity in soldiers after 
carrying the ritie and bandolier during long marches. Fig. 220 
shows a man, otherwise powerful, symmetric and well developed, 
who acquired it in two years' active military service in South 
Africa, during which he had to make long marches with his rifle 
and cartridge belt pressing down on the right shoulder. 

The great specialization of some games 
in which the right arm is almost exclusively 
used is blamed for many cases. Fencing, 
baseball pitching, and putting the shot 
are ready examples. 

In response to an inquiry sent to 21 
men who had the left low^ered only, 3 
acknowledged to left-handedness. 

The patient placed before a mirror can 
almost always assume the correct standing 
posture by voluntary muscular efTort, but 
to him it does not feel normal or natural, 
and he quickly relapses if left to himself. 

In all straight and symmetric exercises 
the weaker side will get more work than 
the stronger, so that movements described 
for flat chest and round shoulders, all of 
which bring in equally the muscles of both 
sides, \\ould be of some value in these 
cases. It is necessary, in addition to this, 
to develop the upper part of the trapezius, 
the rhomboids, and the deltoid of the 
lowered side, and the latissimus dorsi and 

inferior part of the pectorals on the op|)ositc sid.c, and for this 
purpose the following exercises should Ijc gi\en for a lowered 
right shoulder: 

Exercise I. — Position, standing, arms down at the side. Right 
arm forward raise; inhale (Fig. 221); rise on the tip-toes; stretch; 




Fig. 220. — ^Lowering of 
the right shoulder from 
carrying a rifle and pressure 
of a handoh'er for two vears. 



268 



EXERCISE IN EDUCATION AND MEDICINE 



sideways lower; exhale. The left arm should be shoved downward 

while the right arm is raised. 

This exercise brings into action the 
upper part of the trapezius, deltoid, 
rhomboids, and serratus magnus of the 
right side, and the latissimus dorsi and 
lower part of the pectoralis major on the 
left. 

Exercise II. — Position, standing, arms 
down. Right arm sideways raise; inhale; 
forward bend (Fig. 222); upward stretch; 
arm sideways lower; exhale. 




Fiff. 221. 




Fig. 222. 



This exercise has the same effect as the first, with the additional 
advantage of stretching the right side of the trunk more than the 
left, as the body is bent forward. 

Exercise III. — Position, prone, lying on plinth, right arm 
elevated, left arm forced do\^'n\A'ard. Extend the neck and back; 
relax (Fig, 224). 

Exercise IV. — Position, back to the chest weight, floor attach- 
ment; raise and lower the right arm (Fig. 223). This brings 
into action the right deltoid; the upper part of the trapezius; the: 
rhomboids, and the serratus magnus of the right side. 



TREATMENT OF ROUND BACK AND STOOPED SHOULDERS 269 




Fig. 223. 

Exercise V. — Shrugging the right shoulder while holding a 
dumb-bell of 40 or 50 pounds (Figs, 225 and 226) has the contrary 




effect from continually holding the weight anrl keeping the muscles 
in tension. The intermittent contraction and relaxation of the 
muscles tend to strengthen and develop them, and so make them 



270 



EXERCISE IN EDUCATION AND MEDICINE 



shorter when at rest, while continuous tension rapidly stretches 
them and destroys their tonicity. 

The putting up of a light dumb-bell, five or ten pounds, from 
the floor to arms' length above the head, is another valuable 
exercise (Fig 227). 

The nautical wheel (Fig. 34, p. 63) turned counter-clockwise 
also will help to raise a lowered right shoulder. 




Fig. 225. Fig. 226. Fig. 227. 

Hanging exercises, in which the weight is borne by the right 
arm with counter-pressure on the left side, are of slight assistance 
in stretching the latissimus dorsi on the right side, but do not 
affect the upper part of the trapezius or the serratus magnus, both 
of which are relaxed in this position. 

The prognosis is good in all cases if these exercises be followed 
persistently and faithfully in the form of a daily prescription for 
three to six months. Most of the failures are caused by the 
carelessness of both surgeon and patient and by the readiness of 
the tailor to act as their accomplice. 



CHAPTER XVII 

SCOLIOSIS— ITS CAUSES, VARIETIES, DIAGNOSIS, 
AND PROGNOSIS 

When the child begins to walk, the general direction of the 
infantile spine is changed, as described in the previous chapter, 
and the three normal forward and backward curves soon develop. 
Not only may there be undue exaggeration or suppression of 
these curves, as already shown, but during growth lateral devia- 
tions may also occur to overstretch the supporting muscles and 
ligaments, and even to distort the vertebras themselves while in 
their plastic state. 

The integrity of the spine is protected against the onset of 
deformity by three lines of defense of increasing strength: (i) 
the muscles forming an advanced mobile series of outposts brought 
into service, in relays, powerfully but intermittently; (2) the 
ligaments more resistant, but less mobile, requiring long-continued 
and persistent attacks to overcome their normal protective action; 
(3) the bones, which may be compared to the citadel, yielding to 
the influence of deformity only after the other two lines of defense 
have long since been carried. When they have adapted themselves 
to the deformity and have become set in their distortion, treatment 
can hope to be, at best, only cosmetic in character, to conceal the 
deformity rather than to correct it. 

The muscles acting upon the spinal column fall naturally into 
three groups: (i) The anterovertebral, consisting of the psoas 
in the lumbar region, the three scaleni, the longus colli, and the 
sternomastoid in the cervical; (2) the spinoscapular in two layers; 
the trapezius and latissimus dorsi superficially, and the rhomboids 
and levator anguli scapuke beneath them; (3) the spinal, con- 
sisting of the two posterior serrati, superior and inferior, and the 

271 



272 



EXERCISE IN EDUCATION AND MEDICINE 



erector spinae mass, thick and fleshy in the lumbar and cervical 
regions, but thin and tendinous in the dorsal. 

Some of the deeper muscles well developed in the cervical and 
lumbar regions become ligamentous in the dorsal, illustrating the 




■ ! ! ^ I / 

Fig. 228. — The anterovertebral muscles, showing the iliopsoas and quadratus lum- 
borum in the lumbar region, and in the cervical the longus colli, the scalenus anticus 
medius and posticus on the right, and the sternomastoid on the left. 



principle of regression, and this is significant of the relative amount 
of movement in the three regions. 

Movements of the spine are flexion, extension, side bending, 
and torsion. 

Flexion takes place mostly in the lumbar and cervical regions, 
the dorsal backward convex curve being accentuated but slightly. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 273 

Extension is almost entirely in the lumbar and cervical regions, 
even in backward contortionists, who can place the head on the 
hips, the dorsal region remaining comparatively fixed (Fig. 231). 
In side bending from the flexed position of the spine the lumbar 




Fig. 229. — The superficial and deep layers of the spinoscapular muscles; on the 
right the latissimus dorsi and trapezius, on the left the rhomboideus major and minor 
and the levator anguli scapula. 



region is locked, and the movement is in the dorsal region more 
than lower down. It is accompanied by rotation of the bodies of 
the dorsal vertebrae to the convex side of the lateral curve. Side 
bending from the position of extreme extension takes place in the 
lumbar region almost entirely, the dorsal vertebrae being locked. 
18 



274 



EXERCISE IN EDUCATION AND MEDICINE 



Rotation of the bodies of the lumbar vertebrae is to the concave 
side of the lateral curve. 

Torsion in the erect position is greatest in the cervical region, 
gradually disappearing through the dorsal. In the lumbar region 




Fig. 230. — The erector spinae covered by the serrati postici, superior and inferior. On 
the left the attachments are shown diagrammatically 



it is diminished by flexion or extension and is slight, even in the 
erect position. 

The most freely movable regions are most abundantly pro- 
vided with muscles, and it is to the analysis and application of 
their action that treatment of deviations by exercise must be 
directed. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 275 

The frequency of scoliosis among children and youths may be 
gathered from the fact that in an examination of 122 high-school 
boys entered for an athletic meet I found it in 32 cases, or 19 per 
cent. In an examination of 446 athletic college students it was 
found in 19 per cent. In another series of 200 college students it 
was well marked in over 8 per cent., and slight in an additional 
16 per cent. In a girls' high-school, out of 160 examinations, it 
was found in 31 cases, or 19 per cent., accompanied by severe 
backache in 17 cases. The figures of other observers, like Guillam, 
Krug, Hagman, Kalback, Schotter, Eulenberg, Roth, and Whit- 
man, give an average of about 27 per cent, among school-children 




Fig. 231. — In overextension of the spine the bending takes phice principally at the 
neck and loins (Dwight). 



and place the period of greatest frequency between the ages of 
seven and fourteen. 

The causes of scoliosis are both congenital and acquired. 
Among them may be mentioned wry-neck, defective hearing and 
vision, asymmetry (Figs. 232 and 233) or faulty development of 
the bones, like rickets, dislocation of the hip, arthritis, and uneven 
development of the lower extremities from joint disease or other 
causes. Astigmatism has been given a large place in the caus- 
ation of scoliosis by Gould, who has well described the tilting 
of the head in such cases, particularly when reading or writ- 



276 



EXERCISE IN EDUCATION AND MEDICINE 



ing. His experience has been confirmed in case reports quoted 
by Rogers.^ 

'^Case I. — October 7, 1901, H. H., aged seventeen, Ameri- 




Fig. 232. — Lateral curvature from un- 
even extremities and deformed pelvis. The 
black spots mark the posterior superior 
spine of the ilium. 

can school-girl, complained of 
pain through eyes and head, 
extending down the back, and 
aggravated by study. Some 
months previously her phys- 
ician noticed a lateral curva- 
ture of the spine, and an 
attempt had been made to 
correct this deformity by the 
daily use of calisthenics. She 

was wearing glasses given her by an optician, O. D. + 0,50 
C. 90 — O. S. + 0.75 C. 90°, and with them got 0.7 vision, 




Fig. 233. — The result of raising the foot 
three inches to bring the spines of the ilium 
to the same level. 



1 "Journal of the American Medical Association," July 20, 1907. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 277 

but there was noted at once a tendency to tilt the head to 
one side when using them. After examination under a mydriatic 
she was ordered O. D. + i.o ( + ) 0.50 C. 75°; O. S. + 0.50 
(+) 1.0 C. 100° for constant wear. 

"April 19, 1902: The patient had improved greatly, the 
asthenopia was gone, and the spinal defect was not noticeable. 




Fig. 234. — Showin.LC tilting' of head due to asligmati.sm and j^iroducirif^ spinal deformity 

(Gould). 



The gymnastic exercise had, however, been continued, and the 
beneficial result was attributed to this alone." 

It is to bad posture, long continued, in standing, sitting, and 



278 



EXERCISE IN EDUCATION AND MEDICINE 



lying, joined with the carrying of weights in the hands or sus- 
pended from the shoulder, that we must look for the origin of the 
vast majority of cases, which may be classed under the general 
heading of the scoliosis of fatigue. 

A frequent fault in the ' 

standing posture is the habit- 
ual employment of one leg, 
usually the right one, as a 
base, the other foot being used 
as a prop (Fig. 235). This pro- 




Fig. 235. — Lowering of the right shoul- 
der from resting the weight on the right 
leg. One way in which a curve begins. 




Fig. 236. — Pose from an antique statue 
of a boy illustrating the attitude of rest 
with the weight on the right foot. The 
right hip projected and right shoulder 
lowered, forming a C curve. 



duces a C-shaped curve with marked lowering of the right 
shoulder and prominence of the right hip. Many children 
assume this position, in which the strain is borne by the 
ligaments of the hip and spine for long periods, and feel 
uncomfortable when the weight is transferred to the other foot. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 279 

Such cases are nearly always accompanied by rounding of the 
shoulders, flattening of the chest, protrusion of the abdomen, 
and rotation of the vertebra?, all signs of muscular fatigue and 
ligamentous strain. 

The sitting posture is beset with possibilities for deformity. 
The common habit of sitting with one foot tucked up on the seat 
is responsible for some cases, but, above all, the compulsory holding 
of any fixed position for long periods of time. We know that if we 
hold the arm out at right angles the pain and fatigue soon become 
intolerable, and few can stand the strain so long as five minutes. 
The greatest strain falls upon the deltoid, which has no relief from 
continuous action. The same condition occurs in the back and 
shoulders of the school-child forced to remain sitting for any 
unusual length of time. 

The complicated system of spinal muscles, by working in relays, 
postpones fatigue very considerably, the slightest change of move- 
ment bringing into action a new set and relieving the tired ones, 
and this constant desire for rest by movement is the most striking 
quality of all young animal life. 

With the beginning of school-life the child is made to sit from 
three to six hours with but momentary rests at long intervals, and 
the resultant restlessness must be suppressed by the teacher for 
the sake of discipline. The rapid fatigue of the undeveloped 
muscles and the irregular compression of the growing bones go 
far to fix the faulty posture, especially in those who are weak and 
delicate. The process of collapse and tiring of the spinal muscles 
during writing is well described by Fahrner: 

"Before writing begins children sit perfectly upright with 
both scapulcT thrown back ecjually. As soon as writing begins all 
children move their heads slightly forward and to the left. Soon 
head after head drops from the rapid fatigue of the neck muscles. 
In a short time the back also collapses, so as to hang from the 
shoulder-blades supported by the upper arm. Then two distinct 
types of posture are seen. Those writing on the upper ])art of the 
page support themselves upon the desk, and the rounded back 
curves forward. The eyes are three or four inches distant from 



28o EXERCISE IN EDUCATION AND MEDICINE 

the desk, and the support is from three points — the left elbow, 
the chest, and the right forearm slightly. When at the bottom of 
the paper, they lose their third support and have the left elbow 
alone. Add to this a twisting or skewing of the back toward 
the right. The head is bent toward the left shoulder, and the 
eyes brought within six inches of the paper. The onset of this 
deformity is hastened by mental fatigue, which is faithfully re- 
flected in the posture, the face, and the general listlessness of 
the child." 




Fig. 237. — A double curvature encouraged by bed-posture, as seen in the upper picture, 
and corrected by turning over on the other side (Fitz). 

The influence of a bad sleeping posture in the causation of 
curvature has been well pointed out by G. W. Fitz, Boston 
(Fig. 237). The hips and shoulders, being the broadest part of 
the trunk, serve as points of support, and leave the middle portion 
of the body suspended between them, and as the period of sleep 
occupies one-half to one-third of the child's growing time, this 
influence is of importance. Observations on the attitude of 320 
healthy sleeping children (156 boys and 164 girls), made by 
Dr. E. G. Brackett, showed that about 20 per cent, more lie on 
the right than on the left side, while more lie on the back than on 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 281 

either side. The^e figures were confirmed by Hare, but the greater 
frequency of the lying position on the right side is partly explained 
by the fact that the boys observed were all required to lie upon the 
right side when they went to bed to prevent conversation. Two 
hours later they had turned on the face, the back, or the left side. 
As will be seen by the illustration a patient with left convex 
curve in the lower dorsal region should not lie habitually upon 
the left side. 





Fig. 238. — Straight spine with even sup- 
port of the pelvis. 



Fig. 239. — 8 curve caused by uneven sup- 
port of the pelvis in a normal individual. 



Curvature may begin at either end of the spinal column, the 
most flexible parts being in the lumbar and cervical regions. If 
it begins in the cervical region, from torticollis or from eye defects, 
as pointed out by Gould, other curves will be secondary, while if 
the curvature begins in the lumbar region, from unequal support 
of the pelvis, either in sitting or standing, the dorsal curvature will 
again be secondary. An S-shapcd curAc can be produced ex- 
perimentally by raising the left side of the seat to tilt the pelvis, 
making a lumbar curve with the convexity to the right, and a 
compensating cur^■e in the opposite direction (Figs. 238, 239). 



282 EXERCISE IN EDUCATION AND MEDICINE 

Scoliosis is frequently found in more than one member of a 
family, in twins or sisters, in mother and daughter, or aunt and 
niece, so that such facts should be obtained at the examination 
as well as the susceptibility to illness and fatigue, rapidity or 
retardation of growth, and time of dentition. Signs of rickets, 
like bowlegs, the "rosary," or the characteristic shape of the 
head, should be well noted, and the history of any severe con- 
stitutional diseases, as well as the general habits of life, such as 
the length of the school hours, the amount and nature of exer- 
cise, and the standing and sleeping posture. The mother 
should be asked how the curvature was noticed, for it is frequently 
discovered first by the dressmaker in some casual way, such as 
the slipping of the clothing, inequality of the two sides of the skirt, 
or unevenness of the shoulders, and in all such cases it has probably 
existed for a long time unrecognized. The patient should then 
be stripped, the length of the legs measured, the presence or absence 
of flat-foot should be observed, as well as any marks on the body 
from pressure or faulty support of the clothing. The spinous 
processes should then be marked by a flesh pencil, and the levels 
of the shoulders and inferior angles of the scapulae should be noted, 
while the patient stands in a natural position with the heels together. 
Slight projection of one hip can be quickly detected by noticing the 
variation in the size and shape of the space between the arm and 
side, seen from behind, as pointed out by Jakob Bolin. Flexi- 
bility should be tested by having the patient bend to either side 
and then forward, with the knees straight, the Adams' position, 
which best displays any rotation; and the examiner's hands may 
pass up and down the sides of the spine to feel any irregularity. 
The habitual posture should then be found, and the patient 
placed in the best possible position, which should be the keynote 
for future treatment, as Bernard Roth has so well insisted. 

Before beginning a course of treatment the extent of the cur- 
vature should be recorded if we are to follow the effects of treat- 
ment. This record must show the difference in the height of the 
acromia and inferior angles of the scapulas, the deviation of the 
spinous processes from the straight line, the difference in outline 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 283 

and level of the hips and iliac crests, and, again, the picture will 
not be complete unless rotation of the vertebrae is shown in both 
the dorsal and lumbar regions, and, if necessary, the condition of 
the anterior and posterior curves. 

For this purpose photographs are much employed, but the most 
vital objection to their use as routine practice is their expense, 
both in time and money, the difficulty of getting them, and their 
liability to mislead the observer by imperfections or changes in 
the lighting of the figure at different times. Spellissy has devised 
a uniform photographic method which would be of value if the 
following conditions were observed: (i) A standard focal length 
of lens; (2) a standard focus and distance of subject from lens 
front; (3) a standard direction of lighting for recording purposes; 
(4) a standard size of image and of division of chart for compar- 
ative illustrations, and (5) a standard series of poses in faulty, 
habitual, and corrected posture. Plumb-lines are sometimes used, 
and deviations from them are noted at different levels. The 
shoulder-levels have been measured from the ground, and various 
other isolated facts have been taken, but these methods are all im- 
perfect, cumbersome, and lack the uniformity necessary for com- 
parison one with the other. 

Bernard Roth's plan of recording rotation by molding a 
flexible strip of pure tin across the back at the desired level, and 
making a tracing from this upon paper, is easy and accurate. 

Fitz describes a method of photographing the patient behind 
a screen, consisting of a rectangular frame with threads strung 
vertically and horizontally, cutting the entire surface into squares 
of one inch. A rapid method of recording the deviation is by 
attaching a strip of adhesive plaster to the spine and marking the 
position of the spinous processes on it. 

The most accurate and convenient instruments are those 
employing the pantograph method, of which the most elaborate 
is that of Schulthess, which gives a life-sized tracing of all the 
contours. Its size and expense, however, make its general 
introduction impossible (Fig. 240). 

An attempt has been made to fulfil these conditions in an 



284 



EXERCISE IN EDUCATION AND MEDICINE 



instrument which I have employed for some years. It consists 
of a horizontal iron stand into which a rigid upright rod is firmly 
screwed. To this rod two jointed arms are attached by movable 
collars clamped by thumb-screws. The lower arm passes behind 
the patient and fixes the hips by means of clamps, preventing any 
sideways movement. The upper arm passes in front of the 




Fig. 240. 



-Schulthess apparatus for recording lateral curvature (Llining and Schul- 
thess). 



patient and fixes the shoulders. To the collar of the upper arm 
a plate is hinged for the attachment of the pantograph, set to 
make the tracing in the proportion of i to 4. Ruled paper is 
stretched over the plate and held by clips behind. The pointer 
should be adjustable in length, short for the tracing of the spine 
and scapulae; and capable of being lengthened for tracing the 
outline of the shoulders and hips. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 285 

To take a tracing the spinous processes are tirst marked with 
a jflesh-penciL The patient is placed on the stand with the heels 
together, the hips are clamped at the level at the trochanters, and 
the shoulder arm adjusted and clamped after the patient has 
settled into the habitual position. The line of the spine is followed 
by the short pointer (Fig. 241), the gluteal cleft and the points of the 




Fig. 241. — -Making a tracing of the lateral deviation by the author's scolio- 
siometer: a, Pointer which" follows the line of the spinous processes and tips of the 
scapulffi; b, pencil recording the tracing on paper to the scale of i to 4; r, fixed point of 
the pantograph. 



scapula; marked; then an outline of the shoulders and hips is rapidly 
traced by lengthening the pointer to touch the most prominent parts. 
Cross-sections may be taken to show rotation by passing the end of 
the pantograph across the back, at the desired level, the jmtient bend- 
ing forward (Fig. 242). A tracing of this kind gives an accurate map 
of the back, showing the difference in levels, deviation, and rotation, 



286 EXERCISE IN EDUCATION AND MEDICINE 

their extent being to scale, and estimated by counting the squares 
on the ruled paper. 

These tracings should be repeated from month to month 
throughout a course of treatment. 

Diagnosis. — Scoliosis must be carefully distinguished from 
Pott's disease or tuberculosis, symptoms of which are spasm of 




Fig. 242. — Making a tracing of the rotation at the lumbar region. 

the muscles and loss of mobility in the spine, with pain on motion 
or jar, pains in the chest and abdomen, fever, and impairment of 
the general health. Lateral deviations occur in the course of this 
disease, but it is usually a leaning of the body to one side rather 
sharply, instead of a true gradual curve. In later stages a knuckle 
of bone develops at the seat of the disease, but the danger o£ 
mistaking it lies before this has developed. 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 287 

In rickets the malformations of the various bones may usually 
be discovered by examination and measurement, and the other 
constitutional symptoms are characteristic, the curves of the spine 
being generally rather sharp, and often accompanied by great 
thoracic deformity. 




Fig. 243. — Case of tubercular spondylitis simulating scoliosis, showing lateral and 
rotary deformity. The onset was very rapid and the rigidity great. The diagnosis 
was not made until treatment by exercises had increased the deformity and rigidity. 
The deformity was gradually, corrected under treatment by immobilization (Ridlon and 
Jones). 

In infantile paralysis there is a manifest loss of power in the 
affected muscles, which renders its diagnosis comparatively easy, 
especially by the aid of electricity. In these cases the deformity 
usually becomes great, and the condition is resistant of treatment. 
Curvatures resulting from pleurisy and empyema are always 
toward the convex healthy side of the chest (Fig. 244), and are 
easily distinguished by the history and appearance. 



288 



EXERCISE IN EDUCATION AND MEDICINE 



The most frequent form of scoliosis is the total C-shaped 
curve involving the entire back (Fig. 245). 

In his series of 1000 consecutive cases, taken from a large 
private practice, Bernard Roth found 523 presenting this type; 
329 presented a right dorsal and left lumbar (Fig. 246); 72 of his 
cases showed a total right curvature, while ^t, might be classed 
as irregular. This is substantially the same proportion as in 



^ 



^ 




Fig. 244. — Tracing of 1 . 

scoliosis due to collapse / * I ' \ Fig. 246. — Tracing 

of right side after empy- '" of typical 2-shaped 

ema and resection of ^.^_ ^^^_q ^^^^^ -^ ^ curve. ■ 

^ ■ young woman. 

Scholder's examinations of school-children at Laussane. His entire 
table is as follows: 

Among 571 school-children with lateral curvature, out of 
2134 children examined, 60.3 per cent, showed curves convex to 
the left, 2 1. 1 per cent, showed a right convex curvature, and 
8.5 per cent, showed compound convex curves. His totals are: 

Left Convex. Right Convex. Total. 

Total scoliosis 48.1 per cent. 7.8 per cent. 56.0 per cent. 

Dorsal scoliosis 8.4 " 4.3 " 12.7 " 

Lumbar scoliosis 11. 8 " 8.5 " 20.3 " 

Combined scoliosis 8.5 " 8.5 " 

The total curve is most commonly found in school-children, 
and is followed by the right dorsal and left lumbar. Transitional 
cases are nearly always preceded or accompanied by round shoul- 
ders, flat chest, and protruding abdomen, and by general care- 
lessness in carrying the body weight when standing at rest, as 
in Fig. 235. This alone would tend to produce a well-marked 
total curve with the convexity to the left. As this posture becomes 



SCOLIOSIS — ITS CAUSES, VARIETIES, DIAGNOSIS, PROGNOSIS 289 




fixed the bodies of the lumbar vertebra^ rotate to the left, and this 
part of the cur^'e tends to become more pronounced and localized, 
a compensating curve developing in the opposite direction in the 
dorsal region. This process, happily, may be arrested at any 
stage of its course. 

Curvatures beginning at the upper end of the spinal column are 
usually caused in school-children by uncorrected astigmatism and 
by faulty positions in sitting and in writing, where the head is tilted 
to the left and twisted to the right, as 
in facing a strong wind. This causes a 
rotation of the bodies of the cervical verte- 
brae to the right, carrying with it the bodies 
of the dorsal vertebrae, producing the 
characteristic right dorsal curvature, with 
rotation to the right, and followed by a 
left convex lumbar, the level of the great- 
est deviation in these cases being usually 
from the sixth to the eighth dorsal. 

In total curvatures the deviation is 
greatest lower down — about the ninth or 
tenth dorsal, or even at the twelfth. In 
curvatures beginning from some distortion of the pelvis or irregu- 
larity in its support, the curA'ature is usually situated low down in 
the lumbar region (Fig. 247). 

Symptoms. — The symptoms, apart from the deformity, may 
not be very prominent in slight cases. The dressmaker conspires 
to conceal it by making one side of the skirt longer or by changing 
on one side the distance of the arm-hole to the waist-band, but 
patients usually have a feeling of one-sidedness. They are often 
observed to have a distinct limp and a very considerable number, 
especially young women, complain of backache, more or less severe, 
sometimes bilateral, and sometimes on one side only, usually 
situated in either the lumbar region or about the point of the 
scapulae. In severe cases there may be pressure upon the nerve- 
roots, causing pain. The early onset of fatigue, with shortness of 
breath, is common on account of the diminished capacity of the 
19 



Fig. 247. — Tracing illus- 
trating a C curve as a result 
of uneven extremities. 



290 



EXERCISE IN EDUCATION AND MEDICINE 



lungs and interference with the heart action, but these symptoms 
are peculiar to the more aggravated cases. As the deformity tends 
to increase during the growing period, these symptoms may not 
become insistent until the approach to adult life, when the patient 
is prone to develop phthisis or to have disturbance of the digestion, 
impairment of the general vigor, and slow increase of asymmetry, 
with increasing pain in the back, as senile atrophy of the inter- 
vertebral discs progresses. 

Prognosis. — Total functional curves may continue as such 
throughout life, increasing slightly, although, as a rule, they change 
to structural curves and become compound in form as they pro- 
gress. Some permanent deformity is certain in all cases where 




Fig. 248. — Course of the S curve under treatment. 

the vertebrae have become distorted and a functional curve has 
become structural. 

By treatment all but structural cases should be capable of 
permanent cure, and even they should be in every case 
greatly improved, the deformity masked, and the general health 
and efficiency retained. This applies' more especially to children 
who have not yet acquired their full growth. When full growth 
has been attained, before the case comes under observation, com- 
plete cure is not to be hoped for, and the only thing to be expected 
is some improvement in the general condition and a variable 
diminution of the deformity. Cases due to infantile paralysis 
or to the collapse of one side of the chest, from empyema, are 
peculiarly resistant and must be treated with great caution. Cases 
due to rickets are also resistant, although most of them are capable 
of considerable improvement. 



CHAPTER XVIII 

THE TREATMENT OF SCOLIOSIS 

The treatment of scoliosis falls naturally into two divisions: 
(i) The reformation of the physical habits and improvement of 
the general condition; (2) the correction of the deformity by 
exercise, stretching, and support. 




Fig. 249. — The hand in the writing posture as usually ordered, but not practised, because 
to the writer the writing field is hidden by the thumb, finger, and holder (Gould). 

Correct standing ])Osture must be taught by ihc aid of a mirror, 
as described in the chapter on Round Shoulders. This must be 
insisted upon in season and out of season until it can be maintained 
without fatigue. 

291 



292 



EXERCISE IN EDUCATION AND MEDICINE 



Astigmatism should be at once corrected where it is the cause 
of tilting of the head, and the habits of school life should be care- 
fully regulated. 

The writing posture has been much maligned, and even with 
well-fitting seats and desks the present writing position is such as 
to favor the formation of fatigue scoliosis to a marked extent. 
Slanting script has been blamed as an encourager of postural 




Fig. 250. — Change of posture of body and head, the paper shown, and the pen-holder 
angled in order to bring the writing field into view (Gould). 

defects, but the directions given for the correct writing position are 
impossible from a practical standpoint, as has been demonstrated 
by Gould, who shows that the hand in the writing posture, as 
usually ordered, lies between the eye and the writing field, which 
is hidden by the thumb and finger and the pen-holder (Fig. 249). 
As a consequence, the pupil turns the paper to the left, and the 
pen to the right, accompanying this by twisting of the head further 
to the left, with the chin tilted to the right (Fig. 250). 

If the paper, instead of being placed in front of the pupil, be 



THE TREATMENT OF SCOLIOSIS 



293 



placed to the right of the body hne, these difficulties are overcome, 
and the child obtains a clear view of the writing i'leld, the only 
possible deformity then being a forward bending of the head. 
This, he thinks, can be avoided by tilting the desk-top to an angle 
of 45 degrees, a suggestion probably impossible in most schools 
under present conditions, but the shifting of the writing paper is 
easy of adoption, and covers the most serious objection to the 
present writing position. 

The rule for the construction of a well-fitting desk is so simple 
that there seems no excuse for neglecting it. 

The height of the seat from the floor should be such that in 
sitting the feet rest easily on the floor or on a foot-rest. The slope 
of the seat should be backward and downward, in the proportion 
of one in twelve, the depth being about two-thirds the length of 
the thighs and the w^idth that of the buttocks. Making it concave 
adds to the comfort. The back of the seat should have a slope 
backward of about one in twelve from a vertical line, and the back 
support should come to the mid- 
dle of the shoulders and touch 
the small of the back. The 
height of the desk should be 
such that the back edge allows 
fair room to rest the forearm 
naturally with the elbow at the 
side, and the slope should be 
about one to six forward and 
upward, the edge overlapping 
the front edge of the seat by 
about one inch. The desk may 
well be made adjustable for 

distance (Fig. 251, a-b), so as to allow freedom in getting in and 
out, by pushing the desk-lid forward. These points are covered 
in the Garber adjustable desk, described in the chapter on Schools, 
but no matter how well fitting the school furniture may be, unless 
there is constant change aflowcd, scoliosis is sure to develop in 
some growing children. 




Fig. 251. — To show the measurements 
required in determining desk proportions, 
a-b is the distance which is here minus, 
because the edge of the desk overlaps the 
front of the seat. 



294 EXERCISE IN EDUCATION AND MEDICINE 

Poor lighting of the school-room is a third source from which 
scoliosis begins. If the pupil cannot see clearly, he bends forward 
or screws his back, and the same effect is produced if he sits in 
his own light. A well-designed school-room should have windows 
placed high enough to let the light fall over the left shoulder, and 
never directly from in front or behind. 

The raising of one side of the seat will reverse a beginning 
curvature (Figs. 238 and 239), and this may be used as an auxiliary 
means of treatment by placing the patient upon such a seat from 
a half to one hour daily. Where one leg is short, the foot should 
be raised by wearing an insole of cork in the boot; and a child 
who habitually rests with the weight on the right leg, as in Fig. 
235, should be trained to reverse the resting posture by using his 
left leg as the habitual base of support. 

The main corrective treatment of scoliosis must, however, be 
by active exercise and stretching, and the muscles must be de- 
veloped and trained to maintain the correct posture with ease. 
Treatment must be thorough and regular, extending from half to 
one hour daily for six months at least; and even after an apparent 
cure has been obtained, the patient should be kept under close 
observation for at least two years, to check the first signs of relapse. 

As most children suffering from scoliosis are below the normal 
in strength and resistance, it is essential that exercise should not 
be pushed beyond the point of general fatigue, and the greatest 
care should be taken to limit the number of muscle groups exer- 
cised to those more directly affected, so that the resulting fatigue 
may be localized to them and not spread over the whole muscular 
system, for most of the discredit under which the exercise treat- 
ment of scoliosis has labored has been due to the inaccuracy of 
the exercises. 

Every course should begin with what is known as "straight 
work," such as is described for round shoulders, in which the 
muscles on both sides are equally employed, with special emphasis 
laid upon chest development, but in a few weeks one-sided 
movements should be introduced in appropriate cases, such as 
are described for the raising of the right shoulder, and, gradually, 



THE TREATMENT OF SCOLIOSIS 



295 



Stretching movements should be taught, hke those pictured in 
Figs. 172 and 263 (pp. 233 and 302), the right or left foot only 
being used, and the surgeon grasping the left or right hand, and 
so producing a diagonal tension on the spine. All free movements 
should be done in the keynote position, which is found experimen- 
tally by holding the arms 
so as to give the greatest 
correction of the curvature. 
This may be with the right 
arm up and the left arm 
out, or with the right arm 
up and the left arm down, 





Fig. 252. — A girl aged 7 years 
with severe osseous lateral curva- 
ture of the spine, in the "Jiabit- 
ual" posture (Bernard Roth). 



Fig. 253. — Girl aged 7 years, vvfith severe os- 
seous lateral curvature of the spine, when placed 
in the "keynote" posture (Bernard Roth). 



or with both arms above the head, or the right arm extended 
and the left down. It must be found after repeated trials for 
each individual case. 

In applying asymmetric exercises it is to be remembered that 
the most freely movable regions of the spine are the most abun- 
dantly provided with muscles, and a brief analysis of their action 
and the means of isolating their play under normal conditions will 



296 



EXERCISE IN EDUCATION AND MEDICINE 



be of assistance before describing the special exercises employed 
when their action is disturbed by scoliosis. 

In the lumbar region the psoas takes its origin from the bodies 
of all the lumbar and the twelfth dorsal vertebrae, passing down- 
ward and out of the pelvis to be inserted into the small tro- 
chanter of the femur (Fig. 254). The femur can be used as a 
lever to pull on the bodies of the vertebrae by means of the 
psoas. As rotation of the lumbar spine takes place about the 
articular facets, acting as a pivot, and behind the origin of the 
psoas, the right psoas could thus be made to pull the bodies of 
the lumbar vertebrae over to the right, and would tend to un- 
wind a rotation to the left. The problem is to put into action 



i" I 




-^m////////! 




Fig. 254. — Direction of the pull of the psoas on the lumbar spine. 

the right psoas muscle without involving too many additional 
muscle groups. If we flex one or both thighs, the abdominal 
muscles do most of the work. If, however, the right thigh only 
be flexed, and the left heel pressed backward against the table, 
the patient being recumbent, the abdominal muscles may be 
relaxed, and a comparative isolation of the right psoas obtained 
with a little practice (Fig. 255). 

The intrinsic muscles of the back, known collectively as the 
erector spinae mass, including the multifidus and other short deep 
slips, are most complicated in their distribution, this very com- 
plexity being useful in that its strands may be employed in relays, 
the tired fibers being replaced by fresh parts, and the onset of 
fatigue accordingly postponed. 



THE TREATMENT OF SCOLIOSIS 



297 



As a mass it takes its origin from the posterior aspect of the 
sacrum, from the iliac crest, the lumbar spines, and the transverse 
processes. It is very thick and fleshy in the lumbar region, where 
its two main divisions are deiined, the outer tendons going to the 
six lower ribs, just outside their angles, and prolonged upward by 
the accessorius and the cervicalis ascendens, the inner division, 
more thick and fleshy, going to rib and transverse process through- 
out the entire dorsal region, with an additional bundle going from 
the second lumbar spine to the first dorsal (Fig. 230). The 
deeper layers of this inner division fill the hollow between the 
transverse and spinous processes, the general direction being for- 
ward and inward, while in the lumbar region muscular slips go 




Fig. 255. — Raising right foot with weight attached. 

between adjacent transverse processes, as well as between the 
spines. 

The general action of this muscular mass is to bend the spine 
like a bow-string and to pull down the ribs on the active side, at 
the same time increasing lordosis. The quadratus lumborum is 
a depressor of the last rib, and acts with the erector spinas of the 
same side. 

The lumbar and lower dorsal portions of the erector spina? are 
isolated in action alternately in the act of walking, as can be 
readily demonstrated by j)lacing the hands over the loins and feel- 
ing them spring into action at each step (Fig. 259). Support of 
the weight on the right leg involves a contraction of the left lumbar 
erector spina:. Support of the weight on the right arm and the 



298 EXERCISE IN EDUCATION AND MEDICINE 

feet, as in the diagram (Fig. 257), brings into action the right 
erector spinae, but if the support be at the hips, the action is re- 
versed except in the cervical region (Fig. 256). 

In the dorsal region the muscles are much thinner, more 
tendonous, and the intertransversales and interspinales degen- 
erate into ligamentous bands, and the dorsal spine is much less 
directly affected by muscular action than either the lumbar or 




Fig. 256. — Left erector spinae in action during support at hip. 

cervical, but the ribs can be employed as levers, and the thoracic 
cage, with its muscular attachments, can be made an active means 
for correcting deviation and rotation. 

In movements where the humerus is fixed and the spinoscapular 
muscles contracted, the spinous processes are pulled over to the 
active side by the trapezius, the latissimus dorsi, and the rhom- 




Fig. 257. — Action of right erector spin» in dorsal crossing to left side during support 
at feet and shoulders. 

boids. If the pectorals of the opposite side be contracted, an 
additional torsion is exerted on the dorsal spine. 

The dorsal region can be reached through the action of the 
respiratory muscles. The upper ribs being first fixed in forced 
inspiration by the scaleni, serratus posticus superior, and the 
sternomastoid, the thorax is flexed toward the side, showing the 
convexity, forcing out the walls of the collapsed side, and so 
lessening the rotation of the ribs and deviation of the spine. 



THE TREATMENT OF SCOLIOSIS 



299 



In the cervical region the erect spine is extended by the splenius 
capitis and colh, by the complexus, and by the reappearance of the 
intertransversales and interspinals, as muscles after their liga- 
mentous degeneration along the dorsal spine, besides the obliques 





Fig. 258. — Erector spinas in action during 
forward bending. 



Fig. 259. — Left erector spinae in action 
during support on right leg in standing 
or walking. 



and recti of the suboccipital triangle, all forming the thick, fleshy 
mass of the back of the neck. Movement here is very free in 
all directions, most notably rotation or torsion, which takes place 
largely at the first two cervical joints through the action of the 




Fig. 260. — -Torsion of thorax by muscular action. 



inferior obliques and the more superficial muscles, which arc all 
directly accessible to exercise. 

A muscle can be developed only by active contraction and 
relaxation. Continuous tension quickly tires and lowers its tone, 



300 EXERCISE IN EDUCATION AND MEDICINE 

as has been already stated, so that in prescribing exercise it is 
necessary to distinguish between those given for the purpose of 
increasing muscular tissue and power, which should be compara- 
tively quick and frequently repeated, and those which aim at the 
stretching of muscles and ligaments, which should be slow and 
long maintained. 

In describing the gymnastic treatment of scoliosis the curves 
will be considered in the order of their frequency, and without 
attempting to give an exhaustive list of all possible exercises, those 
that are described will be arranged in the form of prescriptions 
for typical cases and illustrated by case reports. 

All exercises and stretching movements should be given daily, 
with a period of rest after three or four movements; they should 
be so alternated and combined that no two employing the same 
muscles in the same way should follow one another and so cause 
excessive fatigue. 

The most frequent deformity is a total left scoliosis or C-shaped 
curve, and the following prescription of exercise would be indicated : 

Exercise I. — Patient standing in the correct position, hands 
at the side. 

Raise the right arm forward and upward; inhale; upward 
stretch; rise on tip-toes and raise the left foot sideways; upvvard 
stretch; lower the arm and foot to the standing position. 

This movement will develop the upper part of the trapezius, 
rhomboids, and deltoid of the right side, raising the shoulder and 
stretching the thorax. At the same time the uneven support 
brings into strong action the lower part of the left erector spinae. 

Exercise II. — Position standing, fingers interlocked behind the 
back. 

Movement : Roll the shoulders backward, supinating the arms 
(Figs. 2 ID and 211), and then bend the body to the left. 

This exercise stretches all the anterior muscles and ligament's 
of the shoulder-girdle, improves its flexibility, and reverses the 
curve. 

Exercise III. — Position standing, left foot forward in lunging 
position, hands on hips. 



THE TREATMENT OF SCOLIOSIS 



301 



Movements: Raise the right arm sideways; inhale; upward 
stretch; forward bend until the right hand touches the floor in 

front of the left foot; upward stretch; 
exhale. This may be varied by 
bending from the standing position 
and raising the left arm (Fig. 262). 





Fig. 261. 



Fig. 262. 



This movement, besides developing the upper right shoulder 
muscles, improves the lung power by filling the lungs in their 
most fa\orable position and compressing the air in the downward 
bending movement. The right side of the thorax is stretched 
durino; the forward bending; movement, and the left latissimus 
dorsi is contracted by pressing downward on the left hip \\'ith the 
left hand. 

Exercise IV. — Patient supine on the ])linth, with the right 
knee over the end, the left arm behind the back, and the right hand 
grasped by the surgeon. 

Movement: Starting with the elbow at the side, the surgeon 
pulls the arm up slowly sideways, the j)aticnt resisting. When 



302 



EXERCISE IN EDUCATION AND MEDICINE 



fully extended above the head, the surgeon exerts as much tension 
as possible, counting five. The patient then draws the arm down 
to the starting position, the surgeon resisting. 




Fig. 263. — Stretching of right side. 

In this stretching movement the two points at which the 
stretching power is applied are the right hip and the right shoulder, 
so that this tension will reverse the curve and stretch the right 
side of the trunk. 




Fig. 264. 

Each of these exercises should be repeated at least twenty 
times, and should be followed by a short rest, after which the 
followinsf should be given: 



THE TREATMENT OF SCOLIOSIS 303 

Exercise V. — Patient lying on the right side with the legs 
strapped to the plinth, the right hand supporting the head and the 
left hand on the hip. 

Movement: Side flexion of the trunk (Fig. 264). 

In this exercise it will be necessary for the surgeon to assist 
most patients at first and to urge them to bring the body as high as 
possible. The entire erector spina? mass on the left side is power- 
fully employed, and the effect may be still further increased by 
placing both hands behind the head. 

Exercise VI. — Patient lying prone with both feet strapped to 
the plinth, right arm extended upward. 




Fig. 265. 

Movement: Trunk extension, forcing the right arm forward 
and the left arm backward (Fig. 265). 

Exercise VII. — Patient lying supine. 

Movement: Raise the right arm forward, upward stretch, 
inhaling slowly; lower to the side, exhaling. 

This should be repeated at the rate of twelve to the minute, 
and the maximum amount of chest expansion secured at each 
repetition. 

Exercise VIII. — Patient lying prone, the left foot only fastened. 

Movement: Trunk extension with the movement of swimming, 
as in Figs. 214-216. This should begin by repeating the swimming 



304 EXERCISE IN EDUCATION AND MEDICINE 

movement five times, followed by a rest. Gradually patients will 
be able to go up to twenty or thirty times without resting. 

These exercises should be followed by a rest. 

Exercise IX. — Suspension, with lateral traction. The patient 
puts the head in a Sayre sling and grasps the cord preparatory 
to self-suspension. A band of webbing is placed about the point 




Fig. 266. — Self suspension with pressure on the left side to correct rotation. 

of the greatest deviation on the left side, usually about the tenth 
dorsal (Fig. 266). 

Movement: The patient, pulling on the cord, raises herself 
from the ground, while the surgeon, by means of a cord and pulley, 
draws her sideways, stretching the right side. Repeat ten times. 

This should be followed by a rest. 

Exercise X. — Right hand on the back of the head, left- hand 
on the hip. 

Movement: Side-bending to the left. 



THE TREATMENT OF SCOLIOSIS 



305 



The treatment should end by deep, firm stroking from above 
downward, about ten or twelve times on each side, using one hand 
to press upon the other. 

The following is a typical case report: 

V. O., aged twenty-one. Consulted 
me April 20th. At the age of eight 
years she fell down stairs, and was con- 
fined to bed for three months. She 
states that since then she has been suf- 
fering from pains in the back at the 
point of the right scapula, burning or 
boring in character, much worse after 
sitting still for any length of time. Has 
been unable to attend school or do any 
work on account of pain and fatigue. 

Examination. — 111 nourished and 
anemic; flat chest; prominent abdomen; 
projecting chin; round shoulders. Right 
scapula one and one-half inches lower 
than the left (Fig. 268). Total left 
scoliosis, with deviation greatest about 
the ninth dorsal. Rotation slight, flexi- 
bility good, the iliac crests even in height. 
Patient winces on pressure over the point of the left scapula and left 
lumbar region. 




Fig. 267. 






\ 

Fig. 268. — Tracings taken at the beginning and after one month's treatment by rest 

and exercise only. 

Prescription of exercises such as described, with one hour's 
rest daily, recumbent, in the afternoon. 



3o6 



EXERCISE IN EDUCATION AND MEDICINE 



May 28th: She has been at work daily for one month. Right 
shoulder still lower, but the improvement very marked and the 
spine almost straight (Fig. 268). Occasional pains, not constant 
in location or duration, probably hysterical in character. General 
condition much improved. To continue daily work at home for 
one month. 




Fig. 269. 



Fig. 270. 



June 30th: Improvement retained. Can attend to social 
duties without any discomfort. The salutary effect of the exer- 
cises on the general condition of this young woman was most 
marked. 

In a right dorsal and left lumbar curvature (Fig. 246) the 
following prescription would be applicable: 

Exercise I. — Position standing, hands on the hips. 

Movement: Raise the left arm and left leg sideways; inhale 
and upward stretch; sideways lower; exhale (Fig. 269). 



THE TREATMENT OF SCOLIOSIS 307 

In this the left side of the thorax, which is contracted by the 
rotation of the ribs on the right, will be stretched, and the left 
lumbar curve will be reversed by the tilting of the pelvis and the 
contraction of the left erector spinse mass in the lumbar region. 

Exercise II. — Patient standing, with the fingers interlocked. 
Rolling of the shoulders into supination, with forward bending and 
twisting to the right (Fig. 270). 

In the flexed position of the spine side-bending is accompanied 
by rotation, chiefly in the cervical and upper dorsal spme, so that 
this exercise will have little effect on the lumbar curve, the lumbar 
vertebras being locked in the flexion of the spine. 




Fig. 271. 

Exercise III. — Patient standing, hands at the sides. 

Movement: Forward lunge with the left foot, the right hand 
on the hip. Raise the left arm sideways; inhale; forward bend, 
touching the floor; rise; exhale; come back to the standing position 
(Fig. 271). 

Exercise IV . — Patient lying supine on the ])linth. Raise the 
right foot twelve inches from the ])linth, ])ressing back with the 
left heel, hands on the hips. 



308 EXERCISE IN EDUCATION AND MEDICINE 

The tension on the right foot should be increased by placing 
shot-bags across the ankle, starting with a weight of five pounds, 
and increasing it to ten or fifteen as the strength allows (Fig. 255, 
p. 297). The patient should be carefully instructed to relax the 
abdominal muscles so that the strain may fall upon the right 
psoas, which will pull the bodies of the lumbar vertebrae over to 
the right and so unwind a lumbar rotation to the left. 

Exercise F.^Patient prone, the right foot fixed, the left arm 
up, and the right arm down. 

Movement: Trunk extension, with the stretching of the right 
arm backward and the left arm forward (Fig. 272). 




Fig. 272. 

Exercise VI. — Patient supine, right knee over the end, as in Fig. 
263, but right arm behind the back, left arm grasped by the surgeon. 

Movement: The left arm is pulled upward and strong tension 
is put upon it by the surgeon. The patient then pulls the arm 
forward and downward, the surgeon resisting. In this way the 
rotation is unwound by the diagonal tension running from the 
right hip to the left shoulder, reversing the curves. 

Exercise VII. — Patient lying on the right side, as in Fig. 264, 
but the right hand on the hip, the left hand behind the head. 

Movement : Side flexion to the left. 

This exercise is aimed at the lumbar curve, which will be 
reversed by the side-bending to the left in the extended position of 
the spine, essentially a motion of the lumbar region, the bodies of 
the vertebrae turning toward the concavity of the curve. 



THE TREATMENT OF SCOLIOSIS 



309 



Exercise VIII. — Patient recumbent, supine. 
Raise the left arm and the right leg; inhale; lower; slowly exhale. 
This should be followed by a short rest. 
Exercise IX. — Suspension by the Sayre sling. 
Movement: Side traction, pressure being placed on the left 
lumbar region. Repeat from ten to twenty times. 

Exercise X. — Arms behind the head; side flexion to the right 

(Fig. 327). 

This should be followed by kneading and stroking, as pre- 
viously described. 

In a left dorsal and right lumbar curve (Fig. 275) practically 
the same exercises may be used, except that in every case the 
opposite leg and arm are employed. 




I 



J 



Ay-< W i<v 



I 



\ 



Fig. 273. — Four tracings illustrating the progress of an S curve under treatment for 

three vears. 



C. C, aged thirteen. Consulted me January 27, 1896. 

Examination showed the right scapula low, left dorsal and 
right lumbar curves with rotation, round shoulders, flat chest, 
protruding abdomen and chin, and general relaxation of the liga- 
ments. 

General health has not been very good. Two sisters had 
already been treated for spinal curvature. 

The indications here would be to develop the erector spina; 
and extensors of the neck, to expand the chest, and develop the 
abdominal muscles and raise the right shoulder, reversing the 
curves. 

The best possible position was one in which the right arm was 
raised and the left stretched horizontally out at the side. 



3IO 



EXERCISE IN EDUCATION AND MEDICINE 



After daily treatment, lasting over two months, the second 
tracing was obtained, the lumbar curvature being practically 




Fig. 274. — Movement for left dorsal and right lumbar curve. 

corrected, although there was still a dorsal curvature with the 
right scapula low. 

She reported twice a week for two months, taking a modified 
daily prescription at home. She then left the city for the summer, 





\ 



u \v 



\ 



J 



V 



J 



V 



R.-L. 






Fig. 275. — Course of triple curve under treatment: Left lumbar, right dorsal, and left 

cervical. 

and the following October a third tracing was taken, showing that 
the improvement was retained. During that winter she reported 
once a week and continued her exercise at home. 



) 



THE TREATMENT OF SCOLIOSIS 3II 

Three years later a fourth tracing was taken, showing that the 
correct position had been maintained. 

It will be noticed from the tracing that the patient has developed 
from a child of thirteen to a young woman of sixteen (Fig. 275). 

Curves due to infantile paralysis will require long-continued 
treatment, especially where they are severe and structural, 
localized and fixed. In some of these cases the best that can 
be hoped for from gymnastics 
is to develop the general mus- 
cular system, and to form com- ' j 
pensating curves abo^'e and ^ \^ > 

below the primary curve, thus 
gi\'ing a general appearance 
of symmetry to the outline of *^- •^^f" "i^* 4^ '^'-o-tuii. 

the back. ^'-- ''^■ 

S. M., aged nine years. Consulted me in September. Six 
years agq he had left hemiplegia lasting six months, which, 
to all appearances, gradually passed away. About two years 
ago he noticed while walking that the left shoulder protruded 
(Fig. 276, i). 

Examination showed a left lateral curvature high in the 
dorsal region. Marked rotation, some pain over the convexity, 
and diminished flexibility. Slight compensating curves in the 
lower dorsal and lumbar region were present. 

After two months of daily exercise and stretching, a second 
tracing was taken, showing the development of the compensating 
curve and the lowering and partial replacing of the left scapula. 
The improvement continued from September until March, when 
a third tracing was taken, showing a lowering of the scapula at the 
expense of an increase of the lumbar curve (Fig, 276, 2). This 
was the extent of the improvement obtained, but the general 
appearance of the back, especially when dressed, was very much 
better, and the muscular development and general efficiency 
greatly improved. 

Where the cur\-ature is due to inequality of the extremities, 
as in the tracing, this must be corrected by raising the heel of the 



312 



EXERCISE IN EDUCATION AND MEDICINE 



/ 



shortened side, which is sometimes all that is necessary (Figs. 
232 and 233, p. 276, and Fig. 247, p. 289). 

One of the most important points in the treatment of all these 
cases is the development of the thorax, and it is remarkable how 
much improvement can be obtained in this direction by respiratory 
and stretching exercises. 

One case, S. R., aged eighteen years, came with persistent 
wearing pain in the back, round shoulders, and lateral curvature. 
There was a strong family history of tuberculosis. 

On October 7th her lung 
capacity, tested by the spiro- 
meter, showed 80 cubic inches, 
November 28th, after a 
little over one month of steady 
work, it was no, and on Janu- 
ary 3d, 125. The pains in the 
back had disappeared, the cur- 
vature was corrected, and her 
general health excellent (Fig. 
277). 
Here was an increase in lung capacity of 45 cubic inches in 
three months. While such a result is unusual, still, after going 
over thirty consecutive cases, I find an average gain of 21 cubic 
inches, and among these were several that have increased from 
30 to 35 cubic inches in less than three months by daily work. 

In structural cases, where the treatment by gymnastics and 
posture is insufficient, stretching and retaining apparatus are 
necessary. 

Among the simplest is the following (Figs. 278 and 279) : 
"The patient lies face downward, with the knees flexed, on a 
board three feet wide and four feet long. Assuming the case to 
be a right dorsal curve, a broad canvas strap is passed around the 
left upper thorax, over and under the patient, and fastened to a 
cleat on the right side of the board. This furnishes a point of 
resistance against the left side of the upper thorax at the level of 
the axilla. A broad canvas strap is then passed around the left 



Fig. 277. — Tracings at the beginning 
and after three months of daily treatment 
for chest expansion and curvature. 



THE TREATMENT OF SCOLIOSIS 



3T^3 



side of the pelvis, above and below, and is fastened to a cleat on 
the right side of the board. This furnishes a point of pressure 
against the left side at the level of the pelvis. A broad canvas 



^UMl^^^^^V 


n 


^mm^m^ 


1 ^ 



Fig. 278. — Stretching board with loops, ready for application to alefl dorsal curve (Lovett). 

strap is then placed around the thorax on the right side at the level 
of the greatest point of the curve. Its upper end is fastened to a 




Fig. 279. — Stretching board with loops, applied to a patient with right dorsal curve 

(Lovetl). 

cleat at the left side of the board; its lower end, passing beneath 
the thorax, is fastened by a string into a pulley attached to a cleat 
at the left side of the Ijoard. By means of this pulley any reason- 



314 



EXERCISE IN EDUCATION AND MEDICINE 



able degree of force may be exerted against the right side of the 
thorax, pulHng it to the left and at the same time reducing the 
rotation, because its upper end is fastened, its lower end moving 
toward the pulley. The efficiency of this apparatus is greater 
than the same movement done during suspension, because stretch- 
ing is done more easily when the spinal muscles are relaxed. 
Patients should be stretched up to the point of mild discomfort 
daily, and kept in the corrected position for fifteen or twenty 
minutes. 

The application of apparatus in severe cases for retaining the 
improvement obtained by gymnastics and stretching need not be 




J 



V 



J 



^ 



K*^- 'i'r 






Fig. 280. — Course of triple curve under treatment by exercise and stretching onlj'. 



taken up here in detail. The steel brace and the plaster jacket 
both have their advocates, but they should be applied only to 
retain the child in the best possible position during the growing 
period, and all apparatus should be • easily removable, so as to 
permit of daily exercises, which should be persisted in for months 
or even years if one is to expect a permanent result. 

Improvement or cure should not be considered permanent 
until the correct position is maintained without apparatus from 
month to month, as shown by repeated records. 



CHAPTER XIX 

EXERQSE AND ATHLETICS AS A FACTOR IN 
DISEASES OF THE CIRCULATION 

To exercise has been assigned the role of cause, as well as cure, 
in most of the disorders peculiar to the circulatory system. 

The heart is a muscle capable of development and liable to 
overwork, and the arterial system shares intimately in changes 
taking place in the central organ of the circulation. 

The heart may suffer from^ 

1. Acute or chronic overstrain, characterized by dilatation, 
hypertrophy, and leakage at the valves. 

2. The accumulation of fat in the walls or in the pericardium. 

3. A slow hardening and degeneration of the heart wall, and 
a lessening resiliency of the arteries, with increased blood-pressure, 
known as arterial sclerosis, in the production of which prolonged 
muscular overstrain has been gi\^en an important place by some 
authors. 

4. Anginal attacks, accompanying dilatation and caused by 
bodily or mental overexertion, frequently associated with arterio- 
sclerosis. 

5. Actual distortion of the vahes, due to inflammatory action, 
accompanying acute rheumatism, chorea, and certain other acute 
diseases. 

In the fifth class the \'al\'es may l^ecome crumpled and the 
orifice reduced in size, causing stenosis, or the flaps may fail to 
meet, the blood-stream leaking back when the contraction is over; 
sometimes both conditions may exist in the one valve. 

In the order of their seriousness valvular defects may ]je 
classified as: First and least dangerous, stenosis of the aortic 
valve (Fig. 281), overcome by a com]jcnsating thickening of tlie 

315 



3l6 EXERCISE IN EDUCATION AND MEDICINE 

left ventricular wall; second, mitral insufficiency (Fig. 282), the 




I 

S D S D S D S 

Fig. 2S1. — Endocardial heart-murmur. Stenosis of the aorta. A systolic murmur in 
the right second intercostal space (Vierordt and Stuart). 

blood regurgitating into the right ventricle through an imperfect 
closure of the valve between it and the lesser circulation in the 




D 




S D S D S D S 

Fig. 282. — Endocardial heart-murmur. Mitral insufficiency. A systolic murmur at 
the apex of the heart (Vierordt and Stuart). 

lungs; third, stenosis, or narrowing of the mitral valve (Fig. 283)^ 
followed by an increase in wall thickness and dangerous dilata- 




s D s D s D s 

Fig. 283. — Endocardial heart-murmur. Mitral stenosis. A diastolic murmur at 
the apex, the first sound valvular or approximately so, if the second sound is heard at 

all (Vierordt and Stuart). 

tion of the right ventricle; and last, insufficiency of the aortic 
valves (Fig. 284), which throws such an increased burden on 




s D s D s D s 

Fig. 284. — Endocardial heart-murmur. Aortic insufficiency. A diastolic murmur 
at right second intercortal space or, better, lower down to the left of this over the 
sternum (Vierordt and Stuart). 

the left ventricle that any overstrain is liable to be suddenly 
fatal. This last condition is the usual consequence of the first, 



ATHLETICS AS FACTOR IN DISEASES OF THE CIRCULATION 317 

since the h3'pertrophy resulting from aortic stenosis soon gives 
place to dilatation of the aortic orifice and consequent regurgita- 
tion of blood into the left ventricle. 

In the physiology of exercise it was explained that by exercises 
of effort the blood-pressure was suddenly raised to nearly 
double the normal, falling quickly to its normal level with the 
cessation of the action (McCurdy). 

In the experiments of Bowen/ on exercises of speed and 
endurance, the rise of the blood-pressure followed the rise of 
pulse-rate, gradually declining until the end of the test, when 
it fell to subnormal and slowly recovered. Accompanying 
tests of either effort or endurance, there is always a temporary 
dilatation of the heart, which must not be looked upon as an 
evil. The heart tends to dilate, as pointed out by Roy and Adami, 
as a matter of economy, whenever its work is increased. This 
economy results, first, from the fact that any muscle works at an 
advantage when somewhat elongated, and, second, because the 
\'olume of the spherical mass changes faster than its surface. From 
this it is clear that, as the heart dilates, the volume of blood pumped 
out by each contraction of the heart muscle increases faster than 
the stretching of its walls, whose inherent elasticity also tends to 
preserve their integrity. It is only when the dilatation becomes 
excessive and is accompanied by greatly increased blood-pressure 
that harm results. This dilatation of the heart, due to the neces- 
sity of increased muscular action, is physiologic, and it is only 
when other symptoms are present that the heart is really over- 
strained. The difference between one acute overstrain and the 
continuous overtaxing of the circulatory apparatus must also be 
borne in mind, as the second condition can only be the result of 
the accumulation of repeated single overstrainings. 

The investigations of Theodore Schott are pertinent to this 
question. He selected wrestling as his exercise — an exercise of 
effort in which the entire muscular system takes part, but which 
combines endurance if carried on for any length of time. The 
results on the heart action arc shown in the six pulse-tracings. 

' " Amer. Jour. Phys.," vol. xi, No. i. 



3i8 



EXERCISE IN EDUCATION AND MEDICINE 



The dilatation of the heart, both to right and to left, was from 
one to two centimeters or more. With the advent of cyanosis 
he also discovered a great lowering of the blood-pressure. He 
affirms that all symptoms gradually disappear in a healthy man, 
and that the severest exercise, even if accompanied by compression 
of the abdomen by means of a belt, has but a temporary 




\^}MM^Mh}MmMm. 






JvJVJ^^JvJvJvJvJ^JVMV M'^'^ 



/ 



Fig. 285. — a, 4 :33 p. m. Before wrestling, b, 4 :45 P. M. After three rounds of 
severe wrestling, c, 4 '.55 P. M. Continued wrestling, d, 4 156 P. M. Renewed wrest- 
ling, f, 5 : 22 P. M. After severe wrestling with tightened belt. /, 5 :42 P. M. After 
twenty minutes' rest, showing approach to normal action (Schott). 

effect, and he concludes that all symptoms of heart insufficiency 
disappear in a few minutes, and that acute overstraining of the 
heart, when it does occur in healthy individuals, tends to disappear 
readily and naturally, the time required depending on the elas- 
ticity of the tissues. With older persons, when the heart-walls, 
have lost a considerable part of their elasticity and the arterial. 



ATHLETICS AS FACTOR IN DISEASES OF THE CIRCULATION 319 

walls have acquired a certain degree of rigidity, overstraining may 
produce permanent deterioration by breaking up the elastic fibers 
and causing the characteristic lesions of arteriosclerosis described 
later on in this chapter. 

Stengel noticed that a systolic murmur appeared in three out 
of nine men just beginning fall practice in foot-ball. This was 
developed on slight exertion and disappeared in the course of 
training. 

I have repeatedly seen it persist through a course of training 
without further symptoms or bad results. Darling reports a 
similar case in an oarsman on the Harvard crew. Two half-mile 
runners, not in condition, showed a marked enlargement and 
murmur, with thrills at the apex immediately after running, and 
a certain hypertrophy is almost always found in athletes who are 
in condition, but even with the heart thus fortified an unusually 
heavy strain may cause an acute dilatation, especially if accom- 
panied by great mental excitement. 

One case reported by Stengel was that of a young man, sound 
and in condition. He had been repeatedly examined within a 
day or two of the injury. In the course of a very trying foot-ball 
game, physically and mentally, he collapsed suddenly. When 
seen, he was bleeding at the nose, cyanosed, with weak, fluttering 
pulse, both sides of the heart enlarged — three-fourths to one inch 
each way. He was completely prostrated, and did not gain 
control of himself for several hours. He then became rapidly 
better, and in a few days seemed quite well. After ten days' rest 
he resumed practice and regular play without any apparent evil 
consequences. He has engaged in athletics more or less actively 
ever since, and is now, twelve years afterward, in excellent health. 

This is the most severe case of dilatation of which I have any 
personal knowledge, although frequently I have found a dilatation 
lasting a day or two, which is always relieved by rest without 
apparent after-effects. 

Clifford-Albutt, in writing of his observations on Cambridge 
students, says: 

"The dilatation is, I think, concerned in second wind. The 



320 EXERCISE IN EDUCATION AND MEDICINE 

healthy heart increases its output, the lungs expand, resistance 
falls, the right ventricle pulls itself together, and second wind is 
established. This process, trying enough to an unsound or defec- 
tive heart or to elderly men, is perhaps never injurious to the 
healthy heart in young adults. I have many times seen under- 
graduates and others look ghastly at the end of a long spurt of 
exercises, but never saw a sound young man the worse for tem- 
porary distress of this kind. If, as in a few cases that I have seen 
again and again in growing youths, dilatation of the heart occurs 
leading to cyanosis, the attending confusion or vertigo is generally 
sufficient of itself to stop the exercise in time." 

With the statement I can most cordially agree, and if per- 
manent or rapidly fatal injury ever occurs, it must be in the 
notoriously unfit or in those whose age should have led them to 
choose more sober pursuits. 

The presence of a murmur without other symptoms is so 
common as to be almost habitual in the young. It is most fre- 
quently found over the pulmonary valves, but when at the apex, 
is not necessarily due to mitral regurgitation. The marked 
acceleration of the onset of fatigue and the slow recovery in the 
untrained or the overtrained man is familiar to all who have seen 
such cases after violent and prolonged exertion, but the ultimate 
recovery of the sound heart from such exertion may be said to be 
universal. 

Blake and Larabee, in their observations on long-distance 
runners, averaging about twenty years of age and covering three 
Marathon races of 24 miles each, write: 

"So far as observed, no permanent injury of any kind has 
resulted from any participation in these races." 

Simple or single overstrain and acute dilatation of the heart 
may then be said to have no immediate after-effects on the healthy 
young adult: The remote after-effects of strenuous exercise has 
also been studied by Morgan and Meylan, the material for their 
observations being university oarsmen, members of the university 
crews of Oxford, Cambridge, and Harvard. A crew man is required 
to row repeatedly a distance of four miles at top speed, the posture 



ATHLETICS AS FACTOR IN DISEASES OF THE CIRCULATION 321 

of rowing being such as to impede the full freedom of the lungs and 
the heart's action, while the movement is of such intensity and so 
quickly repeated as to prevent recovery from the resulting breath- 
lessness. This exercise combines in an intense degree the extremes 
of effort and endurance. 

In his book, called "University Oars," ¥.. H. Morgan took 
the contestants of the interuniversity boat races between Oxford 
and Cambridge, from 1829-69, as his field, and in his investigation 
by mail, received letters from 151 of the 255 survivors, and from 
relatives of the defunct, making a total of 294 rej)orts received. 
Of these, 7 either speak of themselves as probably injured, or were 
so described by their relatives, sometimes with considerable 
reservation. 

On tabulating the crews with reference to expectation of life 
when compared with Dr. Farr's English Life Tables, which 
places the expectation of a man of twenty at forty years, he found 
that the expectation of the crews, allowing the normal expectation 
of their age for the survivors, w^as forty-two years instead of forty. 
Of the 39 deaths, he found that 11 died of fever, 7 of consumption, 
2 from other forms of chest disease, 6 from accident, 3 from heart 
disease, i from Bright's disease, and 8 from various causes not 
connected with athletics. Of the 7 dying from consumption, 
it \\-as found that nearly all had a strong personal or family history. 
They show about the average mortality from diseases of the 
circulatory aj^paratus, as well as from consumption, as disclosed 
by the Registrar-General's report, and it must be remembered 
that they rowed without preliminary medical examination. There 
were no sudden deaths nor rapidly fatal heart cases. 

In America a similar but much more complete set of observa- 
tions were taken on Har\-ard oarsmen by Dr. George L. Meylan, 
of Columbia, who interviewed every sur\-ivor j)ersonally where 
possible, or had the reports made out by their medical attendants. 
He found that 152 men had rowed from 1852-92, of wliom 123 
still survived (November i, 1902), thus allowing eleven years to 
elapse after the last race observed to give time for any evil effects 
to show. He interview^ed 76 men personally, and sent to all a 



322 EXERCISE IN EDUCATION AND MEDICINE 

questionnaire that was most admirable in its completeness. In 
longevity, the first crew (1852) showed an increase of 1.6 years per 
man compared with the selected lives of the insurance tables, in 
which a man of twenty has an expectation of 42.2 years. His 
results were interfered with by a number of deaths of men in their 
prime during the Civil War. By allowing, for those killed in 
battle, the ordinary life expectation of men of their age, the advan- 
tage would be increased to 5.39 years per man. Of the 32 deceased 
oarsmen, only 2 died of heart disease, i of consumption, 2 of 
Bright's disease, 8 were killed in the Civil War and by accident, 
3 died of pneumonia, 2 of apoplexy, i of dissipation, i of paresis, 

1 of cancer, and 10 of unknown causes. In neither of the 2 cases 
of heart disease was rowing given as the cause. The after-health 
was most satisfactory in 68, good in 36, and poor in i. Only 

2 believed that rowing had injured them, one claiming to have 
dyspepsia, and the other an enlarged heart, which, however, had 
caused him no inconvenience since he left college. These results 
would seem to prove conclusively that rowing is not a serious 
factor in the production of early death from arteriosclerosis or 
other circulatory disorders; but it must be remembered that these 
were lives doubly selected — first, for constitutional vigor, and, 
secondly, for muscular strength. The role of muscular overwork 
in the production of arteriosclerosis must, then, be looked for 
rather among those in whom it is carried on for long hours 
under unsanitary conditions, like the miners observed by Peacock, 
and in those whose advancing age and hardening tissues do not 
permit of the rapid recovery from overstretching that is found in 
the normal healthy youth. This obscure and ill-understood 
disease is ascribed to habitual overstrain of the heart, either from 
the excessive use of alcohol, overeating, continued mental strain, 
or from prolonged muscular overwork. If was first described by 
Peacock, about thirty-five years ago, as a result of observations 
made by him on Cornwall miners, who are especially subject to 
continual severe muscular strain. His observations have been 
confirmed later by the investigations of Myers, Clifford-Albutt, 
DaCosta, and others. 



ATHLETICS AS FACTOR IN DISEASES OF THE CIRCULATION 323 

Arteriosclerosis is characterized by hypertrophy of the heart, 
high tension of the pulse, rigidity of the walls of the blood-vessels, 
and the formation of calcareous deposits in the artery walls. The 
process seems to begin by a breaking-up of the elastic fibers of 
the vessel-walls and the formation of scar tissue, which finally 
becomes calcareous. In the condition of atheroma the artery 
becomes hard and feels like a string of beads under the finger. 
The cause of this lowered nutrition in the vessel-walls has been 
ascribed by Sir Lauder Brunton to the diminished pulsation of 
the vessel-wall, caused by the high tension and the loss of the 
normal massage, which produced in them a constant interchange 
of the lymph in the encircling sheath. Each time that the artery 





Fig. 286. — Diagram of the effect of the arterial pulse in aiding the circulation in 
the veins and self- massage of the artery : A is the artery, V the vein, and 5 the fibrous 
sheath which incloses them both, and also a lymph-space, which is shaded in the dia- 
gram. A shows the artery contracted during cardiac diastole with the vein distended 
with blood, and the space with lymph; A ' is the artery distended with blood by the cardiac 
systole, which at the same time drives the venous blood along and empties the lymphatic 
space (Sir Lauder Brunton). 

is dilated by the blood forced into it by the heart-beat the lymph is 
driven out of this sheath, while with the following contraction of 
the artery more fluid again flows in (Fig. 286). It is evident, he 
says, that if the difference between the size of the artery in expan- 
sion and contraction is great, there will be a correspondingly free 
circulation of lymph in the sheath of the vessels, but if the difference 
is very small, the movement of the lymph will be slow and imper- 
fect, the oscillation of the \'essel Ijeing diminished; and it is a fact 
that continued high tension within the arteries leads to arterio- 
sclerosis, to degeneration of the vessels, fibrosis, and atheroma, 
with increased liability to rupture, causing apoplexy, or to car- 
diac hypertrophy and subsequent degeneration. 

Prolonged muscular overwork may act as a cause of this 
condition by throwing into the circulation the products of muscular 



324 EXERCISE IN EDUCATION AND MEDICINE 

waste, particularly hypoxanthin, which itself, when injected into 
the vessels experimentally, will produce abnormally high tension 
and atheroma, but the continual presence of a systolic pressure of 
over 150 millimeters of mercury, as measured on the Stanton ma- 
chine described in Chapter II., must always be regarded with sus- 
picion. When the diastolic pressure is difficult to obtain, by 
reason of the smallness of the oscillation, the suspicion of arterio- 
sclerosis will be strengthened, and if the radial pulse cannot be 
entirely obliterated by pressure of the finger, it will be confirmed. 



CHAPTER XX 

THE EXERCISE TREATMENT OF DISEASES OF THE 
CIRCULATION 

The aim of exercise is to reduce a high pulse-rate by flushing 
the peripheral vessels; to postpone the onset of breathlessness by 
deepening the respiration and improving the muscular tone of 
the heart; to remove the incumbering fat which muffles its move- 
ments; and to prevent palpitation by acting both directly and 
indirectly on the cardiac nerves. 

For this purpose exercises of eiJort and of endurance each have 
had their advocates. 

Exercises of endurance, like walking and hill climbing, have 
had their chief supporters in the persons of Stokes, of Dublin, and 
Oertel, of Munich. 

Exercises of effort have been employed from the time of Ling 
to the present, with such advocates as Bezly Thorne (London), 
Heineman, and the Schotts, at Bad Nauheim. They have always 
been confined to single efforts of the most simple kind, with rests 
between them, accompanied by massage and combined with regula- 
tion of diet and the administration of simple or carbonated brine 
baths. 

It is in the method of giving and the dosage of exercise that . 
authorities differ. Wide recommends kneading, rolling, and 
respiratory movem^ents. He uses abdominal massage, which, 
according to Levin's researches, can reduce an o\-erexcited heart- 
rate, while Schott and others claim that abdominal massage should 
be ])rohibited because it tends to inhibit the heart's action and so 
prevent aeration of the blood. 

All movements of the extremities, especially the legs, draw 
the blood out from the heart and abdomen and act as depletive 
influences. The back trembling given by Zander's machine (Fig. 

325 



326 EXERCISE IN EDUCATION AND MEDICINE 

40) has a powerful influence in reducing a rapid pulse, as have 
vibrations given along the back, from the first to the fourth dorsal. 
These procedures have the added advantages of being applicable 
to a patient who is bed-ridden, and to whom movements of the 
arms and legs must be given with the greatest caution. In slighter 
cases, particularly those in which the heart's action is impeded by 
deposits of fat, the endurance required for Oertel's Terrain Cure 
may be called upon. Sir William Stokes, as early as 1854, wrote of 
the necessity for such patients to "pursue a system of graduated 
muscular exercises" for the symptoms of breathlessness. He 
states: "This treatment by muscular exercise is obviously more 
proper in younger persons than in those ad\'anced in life. The 
symptoms of debility of the heart are often removable by a regulated 
course of gymnastics or by pedestrian exercise, even in mountainous 
countries, such as Switzerland or the Highlands of Scotland or 
Ireland." 

While the Swedes and the brothers Schott have since then 
emphasized the gymnastic side of this treatment, the "pedestrian 
exercise" has been developed by Oertel into a system in which 
he combined walking and hill-climbing with restriction of fluids. 
To the treatment by exercise he adds the drying out of the tissues. 
He made his patients walk on mountainous roads of different 
steepness for a period strictly regulated, gradually increasing the 
time and steepness of the road. It is a form of athletic training 
beginning very cautiously, and based on the principle that function 
makes structure, although in these pathologic conditions it must 
be kept strictly within the limits of resistance by the watchfulness 
of a physician. His system was founded on the result of treatment 
in his own case. He had kyphosis from a fall when a child, rickets, 
and a hereditary tendency to obesity which became so marked 
when he was thirty years of age that the onset of dypsnea, cyanosis, 
edema of the legs, and a diminution of the urine caused him to 
give up his practice. In 1875 he left for a mountainous district, 
and spent there the month of August, where he first experimented 
with his ideas,, against the advice of his attendants, for at that time 
absolute rest was enjoined for such cases. 



EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 327 

The account of this first month is interesting. The first and 
second days he made short excursions in the morning and afternoon 
on level ground, and climbed a hill loo meters high, Breathless- 
ness and palpitation made him stop after taking about twenty 
steps on level ground and after ten in going up hill, while the heat 
and effort made him perspire profusely. The third day he climbed 
a hill 157 meters high. When suffocation seemed inevitable, he 
rested and found relief in taking forced breathing while resting. 




Fig. 287. — Oertel's pulse tracing before beginning treatment (Lagrange). 

This excursion lasted six hours, and he lost much weight from 
perspiration, but that night he had neither irregularity nor palpita- 
tion. 

In the second week he could climb a hill 527 meters high, but 
it took him four hours — twice the time for an ordinary person. 
He had to stop and rest 150 times. He had no evil effects that 
night. Owing to the profuse perspiration, he had great thirst, 
which he relieved by gargling cold water, but he did not drink any 
more than usual. 




Fig. 288. — Oertel's pulse tracing after six weeks' treatment (Lagrange). 

After four weeks he began to take longer excursions and found 
that he could endure them with comparative ease, and, although 
breathlessness came on more quickly than it should, the normal 
action of the heart was rapidly reestablished by resting. 

In six weeks' time he returned to Munich and again took up 
practice, having reduced his weight eight kilos. His pulse remained 
normal in ordinary walking (Fig. 288), and he could go up two 



328 EXERCISE IN EDUCATION AND MEDICINE 

flights of stairs without breathlessness. This improvement was 
kept up by periods of training and rest for eighteen years, when 
Lagrange saw him and reported him in excellent health. 

Shortly after his return to Munich he began to establish- his 
cure. The one at Reichenhall is typical, and a map shows the 
details (Plate i). The course was regulated with care and 
minuteness. The paths were marked with stations, benches 
were placed for resting, and the trees beside the road had bands or 
flags of red, purple, green, or yellow, the colors representing the 
degree of its slant. The exercise was thus prescribed in degrees 
of increasing distance and steepness. 

The range of the Oertel cure is strictly limited. It is, first of 
all, a preventive measure, and can be employed with advantage 
to improve the general nutrition and to prevent fatty infiltra- 
tion from becoming localized in the heart. Even in cases where 
this has already occurred it is still of great value, as it also is 
where the compensation has been already established by milder 
means. 

Where compensation is broken down, and where the patient 
is compelled to remain in bed, massage and the milder treatment by 
gymnastics, which are under more accurate control, have better 
results. They act more directly upon the peripheral circulation 
by unloading the engorged veins without unduly overworking the 
heart itself, and such a course may serve as a good preparation 
for the Oertel treatment, where it would have been dangerous to 
begin with it. 

The application of massage and gymnastics has been taught 
and employed since the time of Ling, but it has been most carefully 
studied and perfected by Auguste and Theodor Schott at Bad Nau- 
heim. The treatment consists of regulated movements of the 
body, beginning at the extremities and employing the large muscle 
masses, combined with massage and the systematic use of car- 
bonated brine baths, such as are found at the Nauheim springs. 
The effect of the baths is to stimulate and flush the skin, and so 
reduce the frequency of the pulse and increase its force. They can 
be prepared artificially. 



PLATE 1. 




EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 329 

The exercises are all duplicate movements, and each one must 
be slov»dy and evenly made, with a definite, firm effort on the part 
of the patient. A short interval should be left between them to 
enjoin slow and regular breathing and to prevent the possibility 
of heart-strain. The patient should be constantly warned of the 
danger of holding his breath during the effort, for by this act an 
undue and unnecessary strain is put on the heart-walls already 
impaired by disease. The exercises should stop short of per- 
spiration and palpitation, and the operator should be on the look- 
out for dilatation of the nostrils, drawing down of the corners of the 
mouth, duskiness or pallor of the cheeks and lips, yawning, sweat- 
ing, or palpitation. 

The pulse should be frequently examined during treatment, 
and examination before and after treatment should show a 
constant reduction in the dulness over both the heart and the 
liver, accompanied by a sense of general relief and freedom last- 
ing several hours. The pulse is increased in volume as its rate 
is reduced, and the breathing is made slower and deeper. The 
color of the lips and face is improved, and the size of the liver, when 
congested, is notably diminished. Marked diuresis usually follows 
after a few days' exercise. 

The movements cover in regular order, first, the muscles of the 
arms and forearms; then those of the trunk, thighs, and legs, 
exercising mildly every important group in the body by single 
contractions. 

The following is the order of the exercises given by Bezly 
Thorne, in his book on the "Schott Methods of Treatment." For 
further instruction in the position of the operator's hands and other 
particulars, the reader is referred to the illustrations. All the 
movements are done with resistance from the patient. This 
resistance must be made very mild at the beginning of the treat- 
ment, the tendency being to employ too much force. As the 
patient shows capacity for enduring the fatigue the amount 
of resistance may be gradually increased, but treatment sliould, 
if anything, err on the side of safety, especially if any signs of 
distress are noticed. 




Fig. 290. 



Figs. 289, 290. — Exercise I. Spread the arms (Fig. 289) until they are in line at 

the level of the shoulders. Bring them together (Fig. 290). 

330 




Fig. 292. 

Figs. 291, 292. — Exercise II. Flex ttie forearm (Fig. 291). Extend the forearm 

(Fig. 292). 
331 




' Fig- 294/ 

?igs. 293, 294. — Exercise III. Raise the arm sideways, palms upward (Fig. 293), 
until the thumbs touch above the head. Sideways lower (Fig. 294). 

332 




Fig. 296. 
Figs. 295, 296. — Exercise IV. Pri-ss together llic knurklt-s of holli limuis will 
the fingers flexed at the simoihI joini. Raise the arms (Fig. 295) ahove liie heaij 
Lower the arms (Fig. 296) to tlic startiiig-|ioinl, in front of the alidoinen. 

333 





Fig. 297, 




Fig. 29S. 

Figs. 297, 2g?,.~Exercise V. Arms forward raise (Fig. 297) until vertically above 

the head. Forward lower (Fig. 298). 

334 




Fig. 299. 




Fig 300. 
Figs. 299, 300. — Exercise VI. Forward flexion of the trunk (Fig. 299). Exten- 

sion (Fig. 300). 
335 





Fig. 302. 

Figs. 301, 302. — Exercise VII. Trunk 
rotation. Tiie operator must change his 
position from Fig. 301 to Fig. 302, as the 
patient turns, keeping up even resistance 
throughout the entire movement, and pass- 
ing partially around him. 



Fig. 303. — Exercise VIII. 
Flex the trunk to the right and to 
the left alternately. Straighten. 



336 



EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 337 



Exercise IX. — This move- 
ment is identical with Exercise II 
(Figs. 291, 292), except that the 
fists are clenched. 



Exercise X. — This movement 
is the same as Exercise IX, ex- 
cept that the arm is at the side. 





Fig. 304. — Exercise XI. Rotate 
the arm forward, upward, back- 
ward, and downward. 



Fig. 305. — Exercise XII. Push both 
arms backward ; draw them forward. 

22 337 




l<'ig. 300. 




Fig. 307. 
Figs. 306, 307. — Exercise XIII. Flex the thigh, with knee bent (Fig. 306). Re- 
lax. Extend the thigh (Fig. 307). 
338 




Fig. 309. 
Figs. 30S, i,og.— Exercise XIV. Extend the leg and bring the straight leg for- 
ward (Fig. 308). Draw the leg liackward (Fig. 309). 



339 



•'-:%*% 




Fig. 310. 




Fig. 311- 
Figs. 310, 311. — Exercise XV. Flex the leg and thigh (Fig. 310). Extend the 

leg (Fig. 311). 



340 



EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 34I 




Fig. 312. — Exercise XVI. Abdiu I ihc k-g. Adduct the leg. 

Exercise XVII. — Arms extended horizontally. Rotate for- 
ward and backward with resistance. 




Fig. 313. — Exercise Xi'/II. J-,xten(l the hand. I'lcx tliu liand. 



342 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 314. — Exercise XIX. Flex the foot. Extend the foot. 

7'his completes the full set of exercises. Many patients at 
first are unable to complete the entire series. The resistance 
should not be very great in the beginning, and should be increased 




Fig- 315- 



EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 343 

only as the patient shows the capacity to endure it. The rate 
should be slo^^• and uniform, and abundant rest given between each 
exercise until the individual's powers and limitations have been 
gauged. Most of them may be done in bed if necessary. 

Some form of artificial respiration has been used by others, 
and may be profitably added to any treatment of these conditions, 
either in the forms already described or in the chest-raising or 
shoulder-raising (Fig. 315) described by Satterthwaite,' in which 
the patient inhales as the operator lifts, and exhales as the operator 
relaxes. This is repeated eight to sixteen times, with one or two 
natural respirations between each movement. Satterthwaite has 
further modified the technic of the Schott treatment by arranging 
the exercises in series of progressing difficulty, which he names 
schemes I, II, and III, including massage of the thigh and 
back. 

The following is a brief outline of the course of exercise carried 
on for the first two weeks: 

Scheme No. I 

1. Chest lifting, lying or sitting 2 minutes. 

Intermission i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Forearm flexion and extension i " 

Intermission i " 

4. Hand and forearm massage 2 minutes. 

Intermission i minute. 

5. Leg and thigh flexion and extension 2 minutes. 

Intermission ., i minute. 

6. Arm and shoulder massage 2 minutes. 

Intermission i minute. 

7. Thigh flexion and extension 2 minutes. 

Intermission i minute. 

8. Chest percussion 2 minutes. 

Intermission i minute. 

9. Trunk flexion and extension 2 minutes. 

Intermission i minute. 

10. Thigh and back massage 2 minutes. 

Total length of seance 28 minutes. 

^ "■ Intern. Clinics," vol. i., thirteenth scries. 



344 EXERCISE IN EDUCATION AND MEDICINE 

This is increased in severity and the order slightly changed in 
Scheme No. II, which is carried on for the third and fourth weeks : 

Scheme No. II 

1. Chest lifting, lying or sitting 2 minutes. 

Intermission i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Forearm flexion and extension 2 minutes. 

Intermission i minute. 

4. Hand and forearm massage 2 minutes. 

Intermission i minute. 

5. Leg abduction and adduction 3 minutes. 

Intermission i minute. 

6. Arm and shoulder massage : 2 minutes. 

Intermission i minute. 

7. Trunk rotation 3 minutes. 

Intermission i minute. 

8. Chest percussion ". 2 minutes. 

Intermission i minute. 

9. Arm separation 3 minutes. 

Intermission i minute. 

ID. Thigh and back massage 3 minutes. 

Total duration of seance ^^ minutes. 

Scheme No. Ill 

1. Chest lifting 2 minutes. 

Intermission i minute. 

2. Foot and leg massage 2 minutes. 

Intermission i minute. 

3. Quarter circling (forward and backward) 4 minutes. 

Intermission i minute. 

4. Hand and forearm massage 2 minutes. 

Intermission i minute. 

5. Head rotation or flexion 3 minutes. 

Intermission i minute. 

6. Arm and shoulder massage 2 minutes. 

Intermission i minute. 

7. Trunk twisting ■ 4 minutes. 

Intermission i minute. 

8. Chest percussion 2 minutes. 

Intermission i minute. 

9. Trunk flexion (laterally). 4 minutes. 

Intermission i minute. 

10. Thigh and back massage 3 minutes. 

Total duration of seance 37 minutes. 



EXERCISE TREATMENT OF DISEASES OF THE CIRCULATION 345 

For the fifth and sixth weeks a further change in the series is 
made, and some new exercises are introduced that might not be 
well borne at the beginning of the course, particularly quarter 
circling and head rotation. 

It will be noticed that in this final series the exercises involve 
newer and larger groups of muscles, and that all the great muscles 
of the body have been exercised. The duration of the seance is 
also longer, and more force should be applied. The movements 
should be very slow, and the intermission should be carefully 
observed, the fault of the operator being usually in shortening the 
intermission, increasing the amount, and using undue force. The 
patient should also be urged to breathe freely and naturally, and 
the operator should be on the lookout for irregular breathing, 
pallor, blueness of the lips or face, or any sign of personal discom- 
fort or disturbance on the part of the patient. Upon the appearance 
of any of these signs exercise must be suspended, since they indicate 
that there has been undue resistance or that the movement has been 
too rapid or the intervals of rest curtailed. Heineman, of Nauheim, 
was strongly of the opinion that no exercise should be used in which 
the hands are brought above the level of the shoulders, on account 
of the increased work required of the heart in raising the column 
of blood to this unaccustomed height. With this opinion Sat- 
terthwaite agrees. Good results may be expected from exercise in 
almost all disorders of the circulatory system except arteriosclerosis. 

The exercise treatment is unusually successful in conditions of 
heart weakness complicated by obesity, where improvement should 
be noted from the first. It is of undoubted value in most valvular 
disease, with signs of failing compensation, the dilatation of the 
peripheral vessels resulting from the exercises being follo^^•ed 
by an improvement in the strength of the pulse and a lowering of 
the rate, an improvement that may be maintained for years. In 
most cases the patients may return to their ordinary occupations 
and duties, and if signs of relapse begin to aj)pear, the taking of 
a course is sufficient to reestablish the ecjuilibrium until the heart 
shares in the inevitable degeneration of advanced old age. 



CHAPTER XXI 

OBESITY: ITS CAUSES AND TREATMENT 

The excessive accumulation of fat must be considered as a 
symptom rather than as a disease. It is due to overnutrition, to 
underoxidation, or to a combination of both acting together. 

When the allurements of the table are too great for the body's 
needs, the surplus is stored up as fat in the tissues least disturbed 
by muscular action, and local deposits are made in the region of 
the abdomen and hips or in a general layer throughout the sub- 
cutaneous tissue of the entire body. 

Heredity has a marked influence in this fat-making tendency, 
about 60 per cent, of cases reported by Anders having this history, 
while its association with gout, that other disorder of overfeeding 
and underexercising, was found in 43 per cent, of his cases. ^ 

The normal oxidation of the ingested food may be hindered by 
a sedentary life involving little tissue waste from muscular exercise, 
or by the mental and physical torpor and habitual inactivity of 
the too ardent pupils of Silenus, whose fat is also protected from 
combustion by the rapidly oxidizing alcohol, which retards all 
tissue waste, and so favors increase in bulk. It may also be 
hindered by lack of the proper functioning of the thyroid gland. 

Fat is a cheaper form of tissue than muscle, requiring as it 
does a less abundant blood-supply, and its presence should be 
considered as an evidence of lowered nutrition. 

As the amount of fat increases the desire for exercise diminishes, 
and the capacity for activity is lessened, because of the speedy 
exhaustion that follows any unusual muscular work. 

Local obesity is frequently found about the waist-line, the 
deposits occurring in the abdominal walls and in the mesentery 
and omentum. This, when excessive, gives rise to a pronounced 

^ See "System of Medicine," Osier and McCrae, vol. i, 846. 
346 



obesity: its causes and treatment 



347 



deformity, simulating tumors, pregnancy, or dropsy. In those 
who do a good deal of walking the legs may remain comparatively 
normal in size, while the abdomen is pendulous. 

Deposits of fat are common in the regions of the neck, giving 
rise to the double or triple chin, and in women, especially, it tends 





Fig. 316. — General deposit of fat in a 
young man. 



Fig. 317. — Excessive deposit of fat about 
the hips only (Moore). 



to accumulate about the hips and buttocks, the Hottentot Venus 
being distinguished by the size of her buttocks, due to the exces- 
sive accumulation of fat in that region. 

The local deposit becomes more dangerous when it is in the 
pericardium and about the heart-wall, Init this seldom occurs 
unassociated with general obesity. 



348 EXERCISE IN EDUCATION AND MEDICINE 

When the obesity is general in its distribution, it may be slight, 
moderate, or excessive. The degrees have been admirably char- 
acterized by a German writer as the enviable, the comical, and the 
pitiable stages, the first presenting itself as a pleasing rotundity, 
the second as a jovial "embonpoint" of the Falstaff type, and the 
third as a sad, unwieldly, and disgusting deformity. 

While the first of these forms requires no definite treatment 
except the employment of every effort to prevent its further develop- 
ment, particularly if complications are present, the second or 
third form calls urgently for reduction by diet and exercise. 

The prognosis in any particular case depends on the reaction 
of the circulation to exercise. If the onset of breathlessness, 
palpitation, irregularity, and thready pulse is rapid or extreme, 
the "outlook is gloomy" (Anders). If, on the other hand, the 
perspiration is profuse, the general condition and color remain 
good, and the pulse strong and regular after exertion, much may 
be expected from a reduction course. 

Most of the causes of death in obese cases are due directly or 
indirectly to affections of the circulatory system, and its condition 
must be the keynote for treatment, as was recognized by Oertel 
in his "terrain cure," described in the previous chapter. 

The fact that obesity is frequently but a symptom emphasizes 
the necessity for a preliminary examination to determine the pres- 
ence of any of the many complications that are usually associated 
with it. In this examination habits of life, particularly with 
reference to diet and exercise, should be noted fully and accurately; 
the pulse should be examined carefully — lying down, standing; 
before and after light exercise, like forward bending, stationary 
running or hopping; the blood-pressure should be estimated and 
a blood-count made to determine the presence of anemia. The 
lungs should also be examined for bronchitis, and a series of 
physical measurements taken, including the weight and girths. 

In all diseases that impose increased work on the heart, like 
arteriosclerosis or emphysema, there is hypertrophy, with danger 
of dilatation and insufficiency, especially when the body is encum- 
bered by excessive fat. The reduction of this fat constitutes one 



obesity: its causes and treatment 349 

of the most valuable means in the treatment of most circulatory 
diseases, unless they are so far advanced as to render restoration 
of the heart to its functional activity impossible. Cases in which 
slight disorders of the circulatory apparatus are present give the 
most satisfactory results, while, even in ad^'auced cases, improve- 
ment can be obtained by beginning gradually and watching the 
heart condition carefully. AMien complicated by diseases of the 
kidneys, like atrophic nephritis, obesity is a real menace, and the 
reduction is not contraindicated, but advised (Von Noorden). 

Chronic bronchitis is a frequent complication of obesity, and 
the removal of superfluous fat will enable the patient to breathe 
more deeply, encouraging a free circulation of blood through the 
lungs, so that such cases sometimes heal under this treatment 
alone. 

Chronic articular rheumatism favors obesity by preventing the 
patient from moving freely, particularly if the regions of the legs 
or pelvis are affected. Anders found it in 35.5 per cent, of his 
cases. The same may be said of gout, the reduction treatment of 
which, through diet and exercise, is of the first importance. Most 
gouty middle-aged men present a history of violent indulgence 
in physical exercise during youth, followed by a luxurious and 
inactive later life, with overfeeding and excessive indulgence in 
alcoholic liquors. 

In diabetes a reduction cure should never be undertaken, 
especially if the obesity be only slight or moderate, although in 
cases where it is excessive, accompanied by heart symptoms, the 
patient should, where possible, be relieved of any excessive fat. 
Only in this way can the heart be protected from excessive strain, 
but it should be used with the greatest caution. 

In selecting cases for the reduction cure three considerations 
should be held in mind: first, the amount of inconvenience the 
obesity causes; second, the presence and extent of the complica- 
tions referred to above; and third, the age and general nutrition 
of the patient. 

When obesity is moderate or extreme, the physician may be con- 
sulted from vanity, which may thus become one of the most powerful 



350 EXERCISE IN EDUCATION AND MEDICINE 

levers in his hands to insure the thorough and complete carrying 
out of the irksome rules that the patient must follow if the desired 
result is to be obtained. This seemingly trivial consideration is 
one on which the success of the treatment often hinges in the 
ease-loving, luxurious class from which so many of these patients 
come. In young and sound adults active courses of five weeks 
or more may be repeatedly undertaken with safety, allowing 
intervals during which the loss of weight is merely maintained. 
In those of advancing age, where the obesity is extreme and the 
vital energies are beginning to fail, a reduction cure would only ac- 
celerate decay and lead to rapid loss in strength and functional 
power, with the continual added risk of heart failure. 

Reduction cures may be divided into three classes or degrees 
of rapidity: 

1. The first degree, in which the loss is very slow, the patient 
losing two or three pounds a month. It applies to those with an 
enviable amount of fat which shows a tendency to increase. It 
does not require great -"^rifice from the patient, who must alter 
her diet by the reduction of fat, starchy, and sweet foods, restrict 
or abandon alcoholic beverages, take only foods of small caloric 
value, and engage in regular active physical exercise. 

2. The second degree, in which loss should be from five to ten 
pounds a month, applies to strong, plethoric subjects, who can 
safely indulge in active exercise. The diet is more strict, and the 
exercises more varied. It is especially valuable for individuals in 
whom complicating disorders of the heart, arteries, bronchi, or 
digestive apparatus render it impossible to take from the start the 
more rapid or — 

3. The third degree of the reduction cure, which should be 
carefully supervised and may be carried out at an institution with 
advantage. As much as thirty pounds a month can be lost with 
safety, but five or six weeks is the longest time during which it 
should be put in force. In most cases it will be necessary to carry 
it on for four to six weeks and then have a month or two of less 
strenuous exercise and regimen, repeating the course thus inter- 
mittently until the desired loss of flesh has been attained. 



obesity: its causes and treatment 351 

The reduction treatment falls under the three heads of diet, 
exercise, and drug thera])y. 

In diet the caloric requirements are reduced to four-fifths of 
the normal in the first course described, in the second to three-fifths, 
and in the third to two-fifths. This is obtained by substituting 
for more nourishing food such artiples as bouillon, coffee, or 
fruits, which have small caloric A'alue. Lean meats should be given 
];reference. Cheese often serves a useful purpose, ])articularly 
in small cjuantilies, as it is very filling. Milk is a useful addition 
to the bill of fare, buttermilk being still more useful. Among 
vegetables, those varieties that grow under ground, as well as those 
that grow in a pod, should be restricted, because they contain a 
large amount of carl)ohydrates. All the other vegetables are 
exceedingly useful articles of diet if they possess small caloric \'alue 
in proportion to their bulk, and consequently fill the stomach 
rapidly, producing a sense of satiety. They also act fa\'oraIjly 
on the function of the bowels. Fruits of all kinds, with the excep- 
tion of bananas, sweet grapes, figs, dates, a^^id raisins, are permitted 
without reserve, as they have a low coloric value, are filling, and 
act well upon the digesti\e a])paratus. Bread is satisfying to the 
eye without possessing great caloric value. 

The intake of li(|uids must be strictly limited. The weight 
of an oljese suljject is ra]jidly reduced by restricting the li(|uids 
to a minimum. This loss of weight is j)articularly apparent 
during the first four or five days of a cure, being due to a direct 
loss of water from the tissues by the air-]mssages, skin, and kid- 
neys, and to the fact that one is inclined to eat less when not 
drinking freely. It also causes absorjjtion by failing to restore the 
amount l(«t by persj^iration. This rapid initial loss is of great 
value to the physician in giving a patient confidence in tlie method 
employed. She is ])ut in the right frame of mind to persexere in 
carrying out the distasteful but stringent rules that must be en- 
forced. Occasionally an initial rise in weight is noticed during 
the first few days on accoimt of the increased metabolism and 
impro\X'd nutrition following unaccustomed exercise. 

Boxers and jockeys who have to reduce their weight rapidly 



352 EXERCISE IN EDUCATION AND MEDICINE 

to a set figure, much below their normal, accomplish it by profuse 
sweating and abstaining from liquids. When excessive, this is 
most exhausting to the system, and in making matches or contests, 
it is frequently stipulated that the man be weighed six or eight 
hours before a fight, so that this abnormal loss of weight may be 
regained in part and the strength restored by eating, and drinking 
copiously of fluids before the beginning of the contest. From 
five to ten pounds may thus be gained in a few hours. Losses of 
weight up to fourteen pounds in an hour and a half have been 
reported during foot-ball games in men at the beginning of training 
by A. A. Stagg, of Chicago University, and James Naismith, 
of the University of Kansas, entirely and rapidly regained after 
eating and drinking. 

The patient's general mode of life must be regulated, always a 
difficult feat to accomplish. Habits of ease and indolence should 
be replaced by greater general activity, and interest in outdoor 
games, like golf and walking excursions, should be created to 
impel her to take a large amount of general exercise. 

The influence of massage is very problematic, according to 
Von Noorden's experiment, referred to in Chapter III., and it is 
to the more active forms of exercise we must go for the best 
results. 

When the accumulation of fat is unevenly distributed, a daily 
prescription of ten exercises should be given, to include the entire 
muscular system, but with emphasis on the regions where the 
deposit is thickest, for fat tends to accumulate in the subcutaneous 
tissue covering the groups that are dormant, like the abdominals 
or muscles of the neck. Such exercises have been shown in 
Figs. 34, 91, 161, 169, 170, 327, 328, and 329. 

When the omentum, mesentery, and abdominal walls are 
excessively overburdened, the exercises shown in Figs. 91, 327, 
328, and 329 are of special value. To these may be added the 
three following, and selection made from them all to suit the 
special case: 

Exercise I. — Patient lying supine, arms above the head, grasp- 
ing a support. Raise both feet twelve inches without bending 



obesity: its causes and treatment 



353 



the knees. Alternately raise and lower the feet (Fig. 318) ten 
times without touching the table. The extent of the raising and 
lowering should not be more than twelve inches. 




Fig. 318. 

This brings the abdominal muscles into action, and should be 
repeated with rests up to thirty times. 

Exercise II. — Patient lying supine, hands on the hips. Raise 
the head and shoulders until the feet can be seen. Twist to the 
right, to the left, and slowly return to the starting position (Fig. 
326). This may be used as an introductory exercise to the next, 
in which the same muscles are employed with greater vigor. 




Exercise III. — Patient lying supine with the feet fixed anrl 
hands clasped behind the head. Raise the body to the u])right 
position, and slowly lower to the starting-point (Fig. 319). This 
23 



354 EXERCISE IN EDUCATION AND MEDICINE 

may be accentuated by having the trunk overextended, as in Fig. 
320, which is a form of the same exercise which can be rendered 
more difficult by having the arms behind the head as shown in 
the position of Fig. 319. 

A prescription should begin with the lightest exercise, and the 
dosage should be increased rapidly in length and severity according ' 
to the muscular strength and the condition of the pulse. 

After each of the first two or three treatments massage is of 
distinct value in relieving the muscular soreness, but it seems to 
have no direct effect in reducing; the weight. 




Fig. 320. 

Accompanying this gymnastic treatment, regulated walking, 
at first on level ground, and then up an increasingly steep incline, 
is of the utmost value, beginning with a climb sufficient to produce 
moderate breathlessness, and increasing the length and steepness 
as the patient's ability improves. This is the Oertel "terrain 
cure," as described fully in the previous chapter. 

The elimination of fluids may be increased by the use of such 
aperient waters as those of Kissingen or Vichy, which are used on 
alternate days, one glass every morning before breakfast or at 
night. 

The principal medicinal agent employed in reduction cures is 
extract of thyroid gland, given in doses up to five grains ihree 
times a day, and stopped promptly if any sign of heart distress or 
weakness appears. 



obesity: its causes and treatment 355 

A daily treatment, such as outlined above, accompanied by 
proper regulation of the diet, should steadily and consistently 
bring do^^•n the weight in moderate and even extreme cases of 
obesity. 

In one of my patients, a young lady aged twenty, it was reduced 
by these means from 20S pounds to 167 pounds in a period of four 
months, which included several weeks lost by interruptions. By 
a very much modified home prescription this improvement was 
maintained at the last examination, taken six months afterward. 

The most remarkable case of reduction reported is that of 
George Cheyne, born in Scotland in 167 1. By the time he was 
thirty his excesses in eating and drinking had brought his weight 
up to more than thirty-two stone (448 pounds), and made him 
very short breathed, lethargic, and listless. He dieted on milk 
and vegetables, exercised freely, and so reduced himself to almost 
one-third (150 pounds). He recovered his strength, and lived to 
the age of seventy-two, writing an essay on health and long life. 

During a reduction cure the heart should be carefully examined 
from time to time, and the work decreased if signs of palpitation 
or edema of the extremities are found. Sometimes, when loss of 
weight is rapid and obtained by means of drugs and diet alone, 
without care to improve the muscle tone and so to support the 
viscera, certain complications arise (constipation, hernia, and 
gastroptosis), particularly in middle-aged and flabby women. Dis- 
placement of the kidneys and uterus may also be traced to the 
rapid absorption of the surrounding fat, and symptoms caused by 
such ptoses ha\'e in rare cases been found to be more troublesome 
tlian the obesity itself. 



CHAPTER XXII 
OTHER DISORDERS OF NUTRITION 

GOUT, DIABETES, RHEUMATISM, GASTRITIS, CONSTIPATION, 

AND HERNIA 

GOUT 

The role of exercise in the pre^^ention and treatment of gout 
occupies an important place in every discussion of this disease. 

Like obesity, with which it is so often associated, gout is usually 
a disease of overnutrition and underelimination, and the indica- 
tions would be to decrease the intake and increase the excretion 
of waste by all the avenues. 

The rules for diet are still the subject of dispute, but all writers 
agree that exercise is of great value in reducing the weight of the 
gouty patient when obese, and of increasing the activity of the 
skin and lungs. 

The nature and dosage of the exercise must be regulated 
according to the condition of the patient. 

In young and vigorous subjects, almost any of the active 
athletic sports appropriate to their age may be engaged in (These 
are enumerated in the Table of Sports, in Chapter VIII.) 

The great majority of patients will require exercises of endur- 
ance, like walking, which should be regulated in distance and 
speed. Golf has a peculiar value, from the fascination it possesses 
for individuals of all ages, a point not to be lost sight of in the 
management of self-indulgent cases. Horseback-riding has the 
added advantage of vigorous massage, especially if the horse be 
trotted, and if the ravenous appetite resulting from the open-air 
exercise be kept within the limits of discretion. 

For those who are unable to take more active exercise a course 
of gymnastics, including duplicate passive manipulation and 
356 



OTHER DISORDERS OF NUTRITION 357 

general massage, is highly beneficial, increasing the elimination 
without undue fatigue. 

It must not be forgotten that a debauch of exercise in a valetu- 
dinarian may precipitate an acute attack by throwing into the 
circulation suddenly the fatigue products and causing an acute 
poisoning, so that great care should be observed to begin gradually 
and increase the amount as the system accommodates itself to the 
necessity for more active excretion. 

Most of the health resorts to which gouty patients flock acquire 
and retain their reputation because of the healthy and moderate 
regimen, purgative waters, and regular habits that are required of 
patients taking the cure. 

DIABETES 

In the hygienic treatment of diabetes exercise has an important 
place, since muscular action favors the combustion of sugar, from 
whatever source it may be derived, and among diabetics the 
presence of constipation favors the onset of coma. 

When present, constipation should be corrected by local and 
general massage daily, and by the simpler forms of free or duplicate 
movements. 

Professor Finkler, of Bonn, tried general muscle kneading in 
fourteen diabetics daily, a twenty-minute treatment being given 
at first, afterward increased to twice a day. They remained on 
a mixed diet. There was a constant diminution in urine, decrease 
in thirst, increase in the body weight, and return of perspiration. 

When the patient is sufficiently strong, he should be made to 
live as much as possible out-of-doors in a dry, warm climate, and 
a daily task should be set for him. The exercise should be gentle 
in character and carried out systematically. Gardening and 
walking, golf, or tennis should be the forms selected, but the 
patient should be warned to stop within the limits of fatigue. 

A course can be carried on to the best ad\'antage in a sana- 
torium, where the conveniences for bathing and massage are 
found, and where the habits of life can Ijc regulated with greater 
hope of success. 



358 EXERCISE IN EDUCATION AND MEDICINE 

RHEUMATISM 

The manifestations of rheumatism, whether they appear in the 
muscles or in the joints, may often be treated by vibration and 
massage, with very considerable success. 

In muscular rheumatism the sternomastoid, the erector spinae 
muscles, and the lumbar fascia are favorite sites for the attack. 
There is probably a coagulation of the semifluid muscular sub- 
stance, with adhesions and retention of waste-products, of which 
uric acid is the worst, causing pressure upon and irritation of the 
nerve-filaments, and spasm of the muscles. 

The pain of this condition is exceedingly acute, and requires 
rest and counterirritation. 

Vibration may be applied to inhibit the pain, by using the ball 
attachment, a medium stroke, and deep pressure several times a 
day over the spinal centers governing these parts, and the soft 
brush and rapid stroke over the affected parts themselves several 
times a day if the pain is acute. Massage is also useful, after the 
acuteness has abated, in soothing the irritation by gentle stroking 
and friction, increasing in force with the improved toleration of 
the subject. The evils resulting from forced inaction in patients 
who are suffering from muscular rheumatism, either in the lumbar 
region or elsewhere, is counterbalanced better by general massage 
than in any other way. The movements used vary from gentle 
stroking to deep kneading of the muscle masses, with manipulation 
to extend the stiffened joints gradually, but without causing severe 
persistent pain. 

Arthritis deformans is an incurable disease, but the inevitable 
progress of deformity can be held back and great comfort can be 
given to the patient by vibration, massage, and manipulation. 

Ankylosis may be prevented by checking the formation of 
adhesions, and the stretching and breaking down of those already 
formed, while atrophy of the muscles, always a pronounced 
symptom, may be delayed. 

Douglas Graham reports most encouraging results in a number 
of cases treated by himself, five out of six showing marked improve- 
ment. His mode of procedure was deep manipulation without 



OTHER DISORDERS OF NUTRITION 359 

friction, passive motion as far as the pain would allow, and some- 
times farther, and resistive movements as soon as they could be 
done. He disregards pain if it rapidly disappears after the treat' 
ment; if it persists, treatment must be suspended. 

He recommends kneading, with one hand, to break up indura- 
tions or disperse effusions, while the other pushes along the circu- 
lation in the veins and lymphatics above the joint. 

Massage would not be used, of course, when the disease is very 
active.^ 

Graham quotes the case of Admiral Henry, who was a sufferer 
from this affliction for twenty-eight years. In 1810, at the age of 
seventy-nine, he was quite crippled, but by means of various 
instruments, made of bone, polished smooth, and hammers covered 
with cork, he persevered in the use of deep friction and percussion 
night and morning for three years. At the end of this time, it is 
said, he had completely succeeded in removing the swellings and 
restoring the use of his limbs. At the age of ninety-one he wrote 
to a friend: ''I never was better, and at present am likely to 
continue so. I step up and down stairs with an ease that surprises 
myself. My digestion is excellent, and every food agrees with 
me. I can walk three miles without stopping." Unfortunately, 
such a case is so exceptional as to have been passed down as one 
of the modern miracles. 

GASTRITIS 

Among the most amenable of the disturbances of nutrition to 
treatment by exercise are constipation and certain cases of chronic 
gastritis and diarrhea. Much attention has already been called to 
the inevitable disturbances of the digestive organs found in those 
leading a sedentary life, especially if they are gormandizers. But 
there is a class of cases in which the gastric disturbances are due 
to nervous causes much more than to indiscretion at the table. 
In advising massage or active movements for cases of chronic 
gastritis, great care should Ije taken, as in diabetes, to stop the 
exercise before reaching the point of exhaustion, and mild exercises 

* Graham, '"Massage," 410. 



360 EXERCISE IN EDUCATION AND MEDICINE 

of endurance, like walking, in addition to massage of the abdominal 
walls, should be the forms recommended. 

In nervous dyspepsia, which is so frequently a symptom of 
neurasthenia or hysteria, the rest cure of Weir Mitchell, with 
careful regulation of the diet, massage, and light resistive exercises, 
leading on to more active movements, should be given. In all, 
such cases of gastritis massage should be given about two hours 
after a meal, and should include pressure and kneading of the 
hypochondriac and epigastric regions, from left to right and 
downward. 

These movements give immediate relief in some cases. They 
force the stomach-contents into the duodenum, stimulate the action 
of the liver, and alternately compress and relax the gall-bladder. 
They should be followed by kneading along the course of the colon, 
and vibratory massage over the spine, from the fourth to the tenth 
dorsal, whenever tender points can be made- out. The relief from 
the feeling of oppression and the more distressing nervous symptoms 
so frequently present in these conditions is often rapid and com- 
plete. 

CONSTIPATION 

Constipation may be due to constitutional peculiarities, to 
sedentary habits, to certain diseases, such as anemia or neuras- 
thenia, chronic affections of the liver and stomach, or the abuse of 
purgatives. A general atony of the intestines accompanies weak- 
ness of the abdominal muscles in obesity and debility, and lassitude, 
headache, and mental depression are the most frequent symptoms 
which attend it; but persistent constipation may exist for weeks 
without other symptoms. Individuals differ greatly in this respect. 
A careful inquiry into the probable causes should be made in all 
cases of constipation. Some change in diet or occupation may be 
responsible, as is so frequently found among college students after 
leaving home. About 12 per cent, of college students complain 
of constipation in their preliminary physical examination, and 
most satisfactory results have been obtained by having them 
follow a list of five simple exercises for the abdominal muscles^ 
which are repeated daily twenty times each. 



OTHER DISORDERS OF NUTRITION 



361 



When the causes are complicated and the condition persistent, 
all the resources of exercise should be brought to bear on the case, 
as well as the regulation of the diet and the drinking freely of 
mineral v/aters or other light laxatives. 

The application should be in the form of massage, vibration, 
duplicate and active movements, and the cultivation of regular 
and systematic habits. The massage should be very deep and 
slow, following the course of the colon, beginning in the right iliac 
region, passing upward to the ribs, across the abdomen, just above 
the unbilicus, and down the left side, terminating in deep, slow, 
circular movements in the left iliac region, over the sigmoid flexure 
and the rectum (Fig. 321). These kneading movements should 




321. — Deep rotating pressure massage (Gant). 



be done very slowly, with firm, deep, and insistent pressure, the 
knees of the patient being drawn up and the abdomianl walls re- 
laxed. 

This part of the treatment should last at least ten minutes daily. 

A cannon-ball covered with chamois leather has been used for 
the same purpose, and most sanatoriums ha\c the Zander machine, 
on which the patient lies face downward, the abdomen resting on 



362 EXERCISE IN EDUCATION AND MEDICINE 

a loose leather diaphragm, beneath which a ball, set in motion 
by a motor, follows the course of the colon, giving continuous 
upward pressure. These movements are not so effective, however, 
as the trained human hand. The administration of vibrations along 
both sides of the spine, from the first to the fourth lumbar, will 
alone give immediate relief in some cases. Massage alone is 
scarcely ever sufficient in the treatment of constipation, accord- 
ing to Bolin, and certain active mo\'ements are necessary to 
supplement the more passive forms. 

Among the exercises that have proved of value may be cited 
the turning of the nautical wheel (Fig. 34) and the trunk rota- 
tion described in Exercises I and II for abdominal weakness 
(Figs. 326, 327, 328). 

Two exercises may be described that act directly by pressure 
on the abdominal contents: 

Exercise I. — Patient lying supine on a couch, arms at the 
sides. Raise the right leg with knee bent. Clasp the hands over 
it and press it in against the abdominal wall. Repeat with the 
left (Plate II, Fig. i). Repeat twenty times. 

Exercise II. — Patient sitting astride a plinth, arms behind the 
back. Trunk circumduction bending well forward to the right, 
then forward and to the left (Plate II, Fig. 2) . Repeat twenty times. 

Circumduction of the pelvis is given most effectively by Zander's 
"camel," the patient sitting on an eccentrically moving saddle, 
or on the "horse," which is a substitute in movement for the trot, 
and riding on horseback itself is to be strongly recommended 
when available. 

The effects of treatment should be noticed from the first, and 
relief is usually immediate and made permanent by continuing 
the improved physical habits. 

HERNIA 

Weakness of the abdominal muscles and fascia is responsible 
not only for many of the more chronic aff'ections of the gastro- 
intestinal tract, due to insufficient support or to lack of the normal 
massage, which the diaphragm and the abdominal walls should 



PLATE II, 




Fig. I. 




I'"lG. 2. 



OTHER DISORDERS OF NUTRITION 



3^3 



give to them, as already described, but the relaxation of the 
openings through which the blood-vessels and other structures 
pass out of the cavity, leads to actual hernia of the viscera. 

When hernia takes place at the umbilicus, there is a stretching 
of the fibrous tissue alone. When it takes place at the femoral 
ring, it is merely a dilatation of the innermost compartment of 
the femoral sheath. Inguinal hernia, which is very much the most 
common form, is, however, in part due to a stretching and spreading 
apart of muscle and tendon, and exercise may be of marked as- 
sistance in strengthening and closing the internal and external 



Lower partof 
t-ra/7sverso//'s 



Fascia transversalis 

Spermatic cord 

Poupar-t's ligament 




Lower part of internal 
oblique thrown for- 
ward 



Fig. 322. — Deep layer, showing internal ring and transversalis muscle. The dotted line 
shows the attachment of internal oblique. 

abdominal rings, and so helping to guard against its advent or 
prevent its return. 

A careful diagnosis is essential to exclude femoral hernia, and 
certain cases in which the bowel does not enter the internal ring, 
but breaks through the conjoined tendon directly beneath the 
external ring. 

The internal abdominal ring is found just beneath the crcs- 
centic arch of the inferior border of the transversalis muscle. 
It is at this point that the vas deferens in the male and the round 
ligament in the female enters the abdominal wall. The trans- 
versalis takes its origin from the outer third of Pou]iart's ligament. 
The internal oblicpie has its origin from the outer half, so that its 
lower fibers cover the internal abdominal ring as by a lid, and the 



3^4 



EXERCISE IN EDUCATION AND MEDICINE 



development of this muscle has a distinct influence on the ring's 
integrity. The external abdominal ring is a slit between the 
tendinous pillars of the external oblique, and every contraction of 



Fascia transversalis 
Spermatic cord 

Poupart's ligament 




Fig. 323. — Attachment of internal oblique, showing the covering of the cord. 

this muscle pulls these pillars together, closing it. This action 
of the muscle serves as an automatic protector of the opening 
during active exercise. 



Poupart's ligament 

Gimbernat's liga- 
ment 




Intercolumnar fibers 



External abdominal 
ring 

Outer or lower pillar 
of external abdomi- 
nal ring 

Fascia triangularis 



Fig. 324. — Superficial layer and external abdominal ring. 

The inguinal canal, which is normally collapsed, is bounded, 
then, superficially from without inward, first, by the external 
and internal oblique; second, by the external oblique alone. 
Hernia may enter the canal at the internal ring, or break in through 



OTHER DISORDERS OF NUTRITION 365 

the fascia that guards its center or inner end, tearing ahead of it 
or pushing aside the weakened conjoined tendon of the trans- 
versalis and internal obhque; but in all cases it makes its exit by 
spreading apart the columns of the external abdominal ring. 

In threatened or actual inguinal hernia much can be 
done by strengthening the external and internal oblicpic and the 
transversalis muscles by active movements. The most suitable 
cases for this treatment are in children and adolescents, where the 
condition is not congenital and where natural growth assists in the 
process of repair, although good results have been obtained up to 
fifty years of age, either where hernia is actually present or where 
there seem to be the premonitory symptoms. One is frequently 
consulted for a dull, aching pain either in one or both inguinal 
regions, particularly after some unusual muscular strain or fatigue, 
by patients who, on examination, show unusually dilated external 





Fig. 325. — Scaver's flat truss pad. 

rings. There is tenderness and a distinct impulse on coughing, 
but no actual hernia. Others, again, in whom hernia is present 
complain of no inconvenience from it. 

One man played foot-ball for years with an enormous scrotal 
hernia, which he did not even support. He then went to Cuba, 
did a great deal of horseback-riding and other violent exercise, 
during which it disappeared, is now quite sound, with no return 
for five years and no necessity for wearing a truss. This is, 
however, far from being a typical case, for strangulation may 
occur at any time, and forms a constant menace. 

All hernias shouhl, of course, l^e reduced and retained, ])refer- 
ably, by a truss that does not present a convexity of surface great 
enough to enter and spread the abdominal ring. The flat pad 
described by Jay W. Seavcr (Fig. 325) is comfortable to the ])atient, 
can be kept clean at all times, and can be worn in the water with- 
out damage. It is especially suitable for young men. It con- 



366 EXERCISE IN EDUCATION AND MEDICINE 

sists of a small steel band, covered with vulcanized rubber, and 
a hollow rubber pad two inches in diameter as the support. 

In a recent hernia, where pain is present, the patient should 
remain quiet for a week or two, to get accustomed to the feel of the 
truss, and should then begin a course of light work for the 
abdominal muscles, as well as more general exercise for the whole 
muscular system. These exercises should be done daily and 
should be increased in number, complexity, and resistance. 

Great stress should be laid on teaching control of the abdominal 
muscles by forced breathing and abdominal exercises. The 
extent to which specialization and rhythmic contraction of these 
muscles can be carried is shown in the movements of the Oriental 
danse du Ventre. As the strength and control of the abdominal 
muscle increases, the work is intensified and extended. Seaver 
allows his patients the most trying gymnastic feats, such as the 
layout on the horizontal bar. The movements, must be varied. 
Such a movement as lying on the back and raising both legs to a 
perpendicular position does not produce the desired result, as the 
strain falls chiefly on the rectus abdominis and psoas muscles. 

The most effective movements are those in which flexion of the 
trunk is accompanied by side-twisting. Great stress should be 
laid on the deepening and raising of the chest, thus drawing up the 
abdominal contents, and relieving the downward thrust of the 
thorax and upper abdominal structures. 

During exercise the abdominal rings should be protected by the 
truss or by the finger placed so as to keep up a continuous pressure. 

A day's work should begin with Exercises Nos. I, II, and IV, 
recommended for the development of thoracic and abdominal 
breathing, and then the following movements should be introduced : 

Exercise I. — Patient lying on the back, one hand behind 
the neck. The other placed so that the middle finger covers 
the inguinal canal and external ring (Fig. 326). Raise the head 
and shoulders, twisting to the right for a hernia of the left side. 
Repeat twenty times without holding the breath. In a double 
hernia both hands should cover the abdominal ring and the 
twisting should be to alternate sides. 



OTHER DISORDERS OF NUTRITION 



567 




Fig. 326. 



Exercise II. — Patient standing, hands clasped behind the head. 
Trunk circumduction to the right (Fig. 327), backward (Fig. 328), 





Fig. 327. 

to the left and forward (Fig. 329). Repeat five times and 
reverse up to twenty times. The Ijreath should not l^e held 



368 EXERCISE IN EDUCATION AND MEDICINE 

during this exercise and the hernia should be kept up by the 
truss. 

This movement brings into action all the abdominal muscles, 
and keeps the chest in the best possible position. 




Fig. 329. 

Exercise III. — Patient seated, facing stall bars, feet fixed, 
hands on the hips, with fingers over the ring. Backward bending 
and twisting to the right and to the left alternately, without holding 
the breath. Repeat twenty times. 

This brings in all the abdominal muscles, the lateral twisting 
especially causing a powerful action of the obliques. It may be 
modified by placing the hands behind the head (Fig. 330) after 
the muscles have been developed enough to stand it, the truss 
being in place. 

The nautical wheel is a valuable piece of apparatus in the 
treatment of this condition (Fig. 34), as are all the lateral trunk 
movements of the Swedish gymnastics. 

Massage with the finger-tips, consisting of kneading and 
petrissage, should be used over the abdominal rings at the end of 
each treatment, to stimulate the local circulation and promote their 
contraction. 



OTHER DISORDERS OF NUTRITION 



369 



Under this developmental treatment, Seaver reports that over 
70 per cent, of his cases have been relieved of the necessity of 
wearing a truss of any kind, and my experience would confirm 
his observations. 

I have also seen the greatest benefit resulting from it in men up 
to fifty-five years of age, the general improvement in tone of the 
abdominal muscles and relief from the constant pain and dragging 




Fig- 33°- 

sensation being complete, while the muscles acquire an alertness 
in contraction that prevents their being taken by surprise by an 
unexpected movement or strain. 

It is frequently due to the sluggish and ineffective action of 
these neglected muscles that hernia is allowed in the first place, 
and their education and development form the best protection 
against its return. 



24 



CHAPTER XXIII 

EXERCISE IN THE TREATMENT OF NERVOUS 
DISEASES 

Massage, mechanical vibration, and active exercise influence 
disorders of the nervous system through their power to control 
pain, to improve the nutrition of the affected region or the general 
health of the patient, and to reeducate disordered or impaired 
coordination. 

INFLAMMATORY CONDITIONS OF NERVES 
In acute inflammation of the mucous membranes of the throat 
and lungs or of the abdominal organs, points painful to pressure 
are found along the spine, at the level from which the sympathetic 
nerve-supply of those areas or organs is derived. 

According to Lightner Witmer,^ the evidence seems to point 
to certain tracts in the spinal cord possessing a specific pain 
function. These are situated a short distance above the segment 
of the cord that receives the peripheral nerves. The viscera refer 
their pain to this pain-organ of the spinal cord through the sympa- 
thetic nerves, which communicate with the spinal nerves before 
entering the cord itself. 

The application of massage or vibration over these painful 
points, which mark the posterior primary divisions of the cervical 
or dorsal nerves, is generally followed by temporary relief of the 
symptoms. This pain-organ is anesthetized, or at least for the 
time being its capacity for feeling pain is exhausted. The points 
at which this stimulation should be applied and its amount and 
nature have already been described in the chapter on Mechanical 
Massage. * 

'" Twentieth Century Practice of Medicine," xi, 1905, 45. 
370 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 37 1 

Vibration over the lower lumbar and sacral regions for inflam- 
mation of the sciatic nerve is frequently followed by immediate 
relaxation of muscular spasm. 

In sciatic neuritis this treatment has been used with great 
success, either in the form of vibrations, as described above, or 
after the method of A. Symonds Eccles, who starts with two daily 
treatments of live or ten minutes after the first few days of 
the disease, gradually increasing them to twenty minutes each. 
He uses friction and kneading directly along the course of the 
nerve and its branches, beginning at the heel and working up- 
ward. 

Before giving a prognosis or undertaking treatment the diagno- 
sis between neuritis and rheumatism should be made. 

Muscular rheumatism is aggravated by motion and relieved 
by rest and warmth, whereas in a true neuritis the pain is worse at 
night, while the patient is warm and at rest, and wears off when he 
is up and moving about. 

The relief from discomfort and the freedom of motion experi- 
enced after each massage are great, although they may be but tem- 
porary, and repeated massage extending throughout the necessarily 
slow recovery increases materially the patient's comfort. In the 
later stages, when the pain is almost gone and stimulation is well 
borne, hacking movements and deep vibration are added. Passive 
mo\ements, in which the thigh is flexed, the knee-joint being kept 
in extension, stretch the nerve and frequently give relief; and, 
finally, toward the end of the treatment, active movements are 
of value in counteracting the atrophy that results from inaction and 
the disease itself. 

Graham deprecates the use of massage over the sciatic nerve, 
and confines his manijnflations to the muscle masses of the front 
and sides of the thigh, with gentle stroking only on the ])osterior 
aspect of the limb. Where hacking and percussion are u.sed, the 
movements should be gentle, and any increase in the pain after 
massage should be a sign to desist. 

Massage is not well borne in Ijracliial neuritis, especially during 
the acuteness of the attack, and absolute rest is then essential. 



372 EXERCISE IN EDUCATION AND MEDICINE 

Only in the later stages may it be employed, and then with pre- 
cautions to avoid a reawakening of the inflammatory process. 

Balfour, of Edinburgh, employed percussion and compression 
for neuralgia in 1819. 

Eccles reports relief by local massage of intercostal neuralgia 
and neuralgia of the cervicobrachial nerves. In the trifacial and 
occipital forms relief is sometimes afforded by gentle percussion 
and kneading of the scalp and face over the seat of pain. 

The improvement in the circulation and the elevation of the 
subnormal local temperature by the warmth of the hand during 
massage are doubtless contributory causes to the relief of these 
symptoms. 

Nerve excitation and vibration for the relief of pain by means 
of percussion became of great interest and importance as a result 
of Dr. J. Mortimer Granville's experiments in London. 

Acute pain he likened to a high note in music, produced by 
rapid vibrations. Dull aching pain he likened to low notes, 
caused by slow vibrations. He attempted to bring discord into 
the rhythm of morbid vibrations, and so relieve or cure the neuralgia 
by his instrument, the "percutor, " in which the rate of blows 
could be changed at will, and the modern vibrator is but a modifi- 
cation of his instrument. 

OCCUPATION NEUROSES 

Scrivener's palsy has become comparatively rare with the 
increased use of the typewriter, but exhaustion neuroses are 
frequent among piano-players and violinists, baseball-pitchers, and 
telegraph operators. 

While no morbid anatomic change can be made out, this 
trouble appears to be the result of an exhaustion or overexcitability 
of the centers controlling the muscular movements most involved. 
The symptoms are cramps and spasms of the muscles, weakness 
and debility, extending even to paralysis, tremors, a feeling of great 
tiredness, with acute shooting pains, and sometimes a subacute 
neuritis, with pain, numbness, or tingling in the fingers. These 
conditions run at best a chronic course, which can be greatly 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 373 

shortened if perfect rest from the habitual movement and daily 
massage and manipulation, with simple gymnastics, be applied. 
In one of my cases, a violinist, a nervous girl of fourteen, with 
fatigue pains coming on rapidly and numbness of the third and 
fourth fingers of the left hand, a daily course of massage, con- 
sisting of friction and kneading of the fingers and small muscles of 
the hand, forearm, arm, and shoulder, accompanied by manipu- 
lation of the joints separately and a few simple gymnastic 
exercises for the fingers separately and together, brought about 
a complete recovery in about two months, enabling her to 
resume her study. This is an unusually favorable result, and 
under the best of conditions the tendency to relapse must be kept 

in mind. 

INFANTILE PARALYSIS 

The onset of this disease is usually without warning, beginning 
with vomiting and fever, and the paralysis may often be found the 
next morning, but usually comes on from two to four days after- 
ward. Sometimes it is not noted for a week or ten days. It is 
accompanied by rapid wasting of the muscles, which, however, 
may be obscured by the presence of fat. Sooner or later contrac- 
tures develop, causing eversion or inversion of the foot, overexten- 
sion or flexion at the ankle, while dangle foot is present after 
complete paralysis of all the muscles. 

There may be overextension of the knees or relaxation of the 
abdominal walls, simulating hernia; the scapula may be winged 
as a result of paralysis of the serratus, and the unbalanced actions 
of the arm and hand muscles may produce marked deformities. 

The paralysis is characteristically random in its distribution 
(Gowers), but the following table shows the most frequent combi- 
nations of regions involved. 



374 EXERCISE IN EDUCATION AND MEDICINE 

TABLE SHOWING DISTRIBUTION OF PARALYSIS 

Duchenne. SeeligmuUer. Sinkler. Starr. MacPhail. Total 

Both legs 9 14 107 40 45 215 

Right leg 25 15 63 20 9 132 

Left leg 7 27 62 27 20 143 

Right arm 5 9 5 7 4 30 

Left arm 5 4 8 4 2 23 

Both arms 2 i i 2 2 8 

Ail extremities 5 2 35 5 4 51 

Arm and leg, same side. .. . i 2 26 4 11 44 

Arm and leg, opposite side i 2 1408 

Trunk i o 22 3 o 26 

Three extremities o o 10 2 2 14 

Total 62 75 340 118 99 694 

The groups involved may be discovered by the wasting, by 
electric stimulation, and by careful examination of the actions that 
are imperfect or absent. The voluntary movement present must 
be estimated with great accuracy, and the difficulty of this has been 
insisted upon by Beevor, in his Croonian Lectures on Muscular 
Movements (1903). 





Fig. 331 . — Incorrect position for test- 
ing the action of the triceps. 



Fig. 332. — Correct position for testing the 
action of the triceps. 



Among the fallacies that may occur are the confusing of the 
action of gravity for muscular action. A slow relaxation of the 
active biceps may be confounded with contraction of the triceps 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 375 

when the bent arm is slowly straightened \\-hen hanging at the 
side, whereas if the arm be first flexed and the elbow be held at 
the level of the shoulder and the patient told to extend it, he will 
be unable to do so (Figs. 331 and 332). 

i\nother error that must be guarded against is the crediting 
of a muscle with contractile power when the movement is the 




Fig. 333. — Correct position for testing the action of the flexors of the elbow. The 
swinging of the arm is thus prevented. 

result of the action of accessory muscles. In flexing the arm where 
the l:)iceps is affected, the contraction of the supinator longus and 
brachialis anticus may disguise the true lesion. The habit that 
patients acquire of jerking the arm or leg u])ward or forward, and 
so simulating the movement of muscles which are actually inert, 
must also be detected (Fig. 333). 



376 EXERCISE IN EDUCATION AND MEDICINE 

These fallacies should be demonstrated to patients in order 
that they may not be deceived as to the actual condition present. 

The outlook for complete recovery of a group long paralyzed 
is bad, but a gradual restoration of power may go on throughout 
several years, and Jacob Bolin reports the return of contractility 
after ten or twelve years. If these cases are neglected, however, 
the atrophy becomes extreme, the growth of the bones is retarded, 
and unopposed active muscles contract and produce deformities. 

Treatment may be begun as soon as the child can bear friction 
of the affected part. 

It should consist of massage of the affected region from the 
periphery to the center, friction with deep kneading, and stroking 
to increase the circulation, which is always defective, as shown 
by the constant subnormal temperature. 

A splint may be necessary to prevent overstretching of the 
paralyzed muscles from the unopposed action of their uninjured 
antagonists. Whenever any voluntary action remains in the 
affected muscles, it should be carefully fostered by gymnastic 
exercises, to train the patient's will-power and concentration. 

Every means must be used to maintain the nutrition of the 
muscles, so that recovery of the injured centers in the cord 
may find well-nourished muscular tissue on which to act. Flan- 
nel bandages or a covering of rabbit skin should be kept on the 
limb, so that its temperature may be continually kept equal to 
or above its fellow, and the muscles, bones, and joints given 
the increased blood-supply. 

The technic of massage may be taught to the mother or nurse, 
to be continued daily at home, in addition to the less effective 
stimulation by electricity, and it should be persisted in throughout 
the entire period of growth, where necessary, accompanied by 
frequent examinations and measurements. 

NEURASTHENIA 

Hysteria and neurasthenia require massage and resistance 
movements for their complete management. In Weir Mitchell's 
treatment for these affections he first counteracts the evil effects 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 377 

on the digestion of overfeeding and continual rest in bed l)y massage 
and gymnastic movements, to reaccustom the patient gradually 
to the muscular tasks of daily life. 

His custom is to begin with a general massage after the first 
few days of milk diet, the hour chosen being midway between two 
meals, the patient remaining in bed. The operator starts with 
the feet, continues the manipulations up each leg, then to the 
muscles of the loins, spine, abdomen, and chest. The order of 
movements is described in the chapter on Massage. The entire 
treatment lasts about half an hour, and is gradually increased up 
to one hour, followed by an hour of rest. This is continued for 
at least six weeks, and then half an hour is devoted to massage 
and the other half to movements of flexion and extension of the 
limbs and trunk, with resistance. In the less severe cases confi- 
dence is put in the more active forms of exercise. One young 
man referred to me by him began by wrestling exercises in 
which at first he did little more than gently resist the various 
positions, locks, and throws. The resistance gradually in- 
creased in force and duration until, at the end of three 
months, he had gained sixteen pounds in weight and had 
impro^^ed so much in strength, courage, and vigor that he 
was sent home cured. Other cases derive the greatest benefit 
from an active outdoor life, in which camping, swimming, walking, 
riding, and wrestling form a great part of the day's program. 

Exercise should be made as simple and interesting as possible, 
the object being to improve the nutrition to the utmost without 
unduly exhausting -the attention or overtaxing the coordination. 
For this reason exercise demanding skill and concentration, like 
fencing, should be avoided. 

STAMMERING 

Exercises of skill are employed almost exclusively to correct 
such disordered coordinations as stammering and stuttering, 
where the utterance of intelligible speech is hindered or ])reventcd 
by convulsive and disorderly contraction of the muscles of resj)ira- 
tion, phonation, or articulation. 



378 



EXERCISE IN EDUCATION AND MEDICINE 



Stammering occurs in about i per cent, of school children. 
Although accurate statistics are hard to get, the Germans show 
about 1.22 per cent, in the schools, whereas Hartwell's statistics 
show about 0.78 per cent, among the children of Boston. 

Stammering is exceedingly contagious in a class, and rapidly 
spreads among school-children, making schools, according to 
Melville Bell, veritable nurseries of stuttering. 

It has been attributed to the forcing of their education before 
the brain is sufficiently developed to govern the power of vocal 
utterance, so that a course of treatment would begin with gymnas- 
tic exercises, such as described in Chapter XIV, for the breathing 
muscles, the first to function in the development of the child, 
while, later on, the muscles of phonation, and, lastly, those of 






Fig. 



54. — The points of contact between the tongue and palate in the formation of 
the sounds L, R, and K (G. Hudson Makuen). 



articulation, are trained. Treatment would thus be based on the 
preliminary development of the fundamental and intermediate 
mechanisms, ending with the finest and most specialized coordina- 
tions. 

Audible speech is caused by the blast of air driven from the 
lungs by the muscles of expiration through the slit of the glottis, 
bounded by the vocal cords, whose approximation is varied by the 
laryngeal muscles, into the mouth, where it is formed and modified 
by the muscles of the palate, tongue, and lips. The complete 
production of ^ speech, then, is effected by a coordination of muscles 
in the chest, throat, and mouth respectively. 

Hudson Makuen lays special emphasis on the difference 
between ordinary passive breathing and the breathing of voice 
production, or "artistic breathing," the function of passive breath- 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 379 



ing being simply to aerate the blood and eliminate waste-matter, 
while breathing for voice production is to set the machinery of the 
voice in motion and to control this motion as a definite voluntary 
muscular process. 

The first muscular act in breathing for voice production is a 
slight inhalation, putting the respiratory muscles and the thorax 
into an active position. He finds that nearly all speech defectives 
fail at this point. 

When this is done properly, the column of breath raised upon 
the diaphragm is ready for its impact against the vocal cords — an 
impact which must be made with the greatest nicety and control. 
This movement of expiration for voice production he attributes 
to the depression of the lower ribs by the diaphragm — a muscle of 






rig. 33; 



L R K and G 

-The position of the tongue in producing the sounds L, R, and K (G. 
Hudson Makuen). 



inspiration in ordinary respiration, whereas in the "artistic " 
breathing needful in voice production it becomes a muscle of ex- 
piration, not only by preventing the pulling up of the ribs, but by 
pulling them downward and inward. Proper coordination of the 
intercostal and abdominal muscles in addition to this action of the 
diaphragm is, of course, essential to the [jroduction of good tone. 
Treatment of stammering would then be begun by the training 
of this respiratory coordination by itself, which is done by articu- 
lating a series of syllables, using for each a single expiratory effort. 
The muscles that control the ^•ocal cords arc also trained by 
exercises; and the coordination between the muscles of expiration 
and the larygneal muscles are then trained to act together, since 
many stammerers vocalize at the wrong time, there being no column 
of air ready when the cords are in the riglit position, or vice versa. 



380 EXERCISE IN EDUCATION AND MEDICINE 

The pharynx, the palate, the tongue, and the hps, organs of 
articulation which mold the voice into speech, are also controlled 
by voluntary muscles. Where there is any organic defect in them, 
such as shortening of the muscular fibers, cleft palate, or harelip, 
this must be corrected, and the rest becomes a purely educational 
process. 

Care must be taken to distinguish between lack of development, 
faulty habits, and disease in the speech center of the brain, for in 
the last class of cases the outlook is hopeless. 

The entire treatment of functional stammering and stuttering 
is based on the physical training and coordination of the mechan- 
isms of speech, the proper use of the muscles of respiration with 
reference to voice production, the training of the vocal muscles, 
and the education of the muscles of articulation. 

Exercises are given to instruct the patient in the elementary 
sounds of the language, how to shape the lips, or where the tongue 
is to be placed, and this training requires patience and perse- 
verance until the defect is finally overcome. 

The success that has attended Makuen's clinic on speech 
defectives is in great part due to the care with which the breathing 
and vocal exercises are graded, and the excellence of his discipline 
in inforcing their accurate, thorough, and persistent practice. 

The high-pitched, falsetto, or eunuchoid voice, which occa- 
sionally occurs in men otherwise normal, can be corrected, accord- 
ing to E. E. Clark,^ by a course of vocal gymnastics and singing 
exercises, beginning with a note of high pitch and then singing 
down the scale until the lowest possible note on the register is 
reached. The voice is then kept at this pitch, and the low notes 
are repeated ten or fifteen times. The patient is then taught to 
read aloud in the deep tone secured by singing his way down the 
scale. Makuen secures the same result by training the patient 
to lower the position of the larynx during phonation. 

CHOREA 

Chorea is a disturbance of coordination characterized by 
irregular involuntary contraction of the muscles, accompanied by 

1 ''Medical Fortnightly," St. Louis. 



EXERCISE IN THE TREATMENT OF NERVOUS DISEASES 381 

psychic disturbances, found mostly in young children, the propor- 
tion of girls to boys being 3 to i. 

It occurs especially in abnormally bright, active-minded 
children, who are forced ahead of their grade in school, and are 
subject to the excitement of competition for prizes. While there 
are no constant anatomic changes found in the nervous system 
after death, the tendency to endocarditis is such that in no cases 
of autopsy the effects were noted in nearly loo. 

The duration of an attack is very variable — from two to three 
weeks to the same number of months — with an average of about 
eight or ten weeks. 

Because of this great liability to endocarditis the heart should 
be carefully examined in all cases. The presence of a murmur 
alone does not indicate endocarditis, since the disease occurs most 
frequently in nervous young girls in whom heart murmurs are 
almost the rule. If the apex is in the normal position and the area 
of dulness is not increased vertically or to the right of the sternum, 
there is probably no serious valvular disease. 

The treatment of the acute attack consists of rest, isolation, 
and tonics. Where the jerky movements have abated, the appli- 
cation of general massage is of value, and the importance of 
gymnastic exercise cannot be overestimated during convalescence. 

When the acuteness of the attack has subsided, the treatment 
should be begun with massage for the first few days, followed by 
simple, slow, resisted movements, and later on by rhythmic 
exercises sufficiently active to tire the muscular system moderately. 
This should be done with the patient by herself if possible, and 
any excitement or competition of class drills should be sedulously 
avoided. 

The keynote of such treatment is the rhythmic repetition of 
simple movements to o\-ercome the irregularity of the twitchings, 
and great strain or fatigue on the attention of the patient should 
be eschewed. 

The practice of sim])le dancing exercises to music is of the 
utmost service, emphasizing the rhythm and taking away the 
mental strain necessary to follow movements done to command. 



CHAPTER XXIV 

THE TREATMENT OF LOCOMOTOR ATAXIA BY 

EXERCISE 

Locomotor ataxia, or tabes dorsalis, is a degeneration of the 
posterior roots and columns of the spinal cord, produced by 
exposure to cold, syphilis, or some other acute poisoning of the 
nerve tissue. 

In reading the literature of the subject one is struck by the 
multitude of theories and the inadequacy of any one of them to 
explain many of the symptoms. 

The hypothesis that is of most interest in connection with the 
application of exercise is that of Edinger, called the " exhaustion 
theory, " in which he believes that the cells of the body are normally 
in a state of equilibrium, one with the other, so that if a cell be- 
comes weakened by disease, other cells lying beneath it will crush 
it out in their growth. Again, when the amount of work required 
from a group of cells is too great, even if their vitality be perfectly 
normal, they may succumb simply from their inability to recuper- 
ate and regain the loss of tissue due to their excessive activity. 
A similar condition is found in occupation palsies. The nutrition 
of the cells may be impaired through toxins circulating in the 
blood, especially if they have a selective action on certain parts of 
the nervous system; and nearly 90 per cent, of tabetic patients 
show a history of syphilis. 

The exhaustion theory would help to explain the frequency of 
the first appearance of ataxia in the lower extremities, the neurons 
governing them being constantly employed in the maintenance of 
equilibrium. 

Cases may be cited where ataxia has first appeared in the arms, 
owing to overfunctioning. One case reported by Mott occurred 
382 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 383 

in a mounted policcmun in whom the symptoms started in the 
arm with w^hich he held his horse's reins. 

In tabes the sensory nerves are also affected, and the eyes show 
a characteristic ojjtic atrophy with the Argyll-Robertson pupil 
Men being more ex|josed to these fatigue influences than women, 
we would expect to find its frequency greater among them; and the 
proportion is actually about lo to i, and James Stewart has 
noted its frequency among lumbermen who have lived a hard life 
in the logging camps during the winter and spring months. 

The motor symptoms are first noticed as increased clumsiness, 
especially in the dark, or difficulty in maintaining the equilibrium 
when washing the face with the eyes shut (Osier). When the 
patient stands with feet together and eyes closed, he sways and 




Fig. 336. — Hypotonia of the muscles of the pelvis and spinal column ( l-rLnkcl;. 

may even fall if the surgeon does not steady him (Romljcrg's 
symptom). On turning quickly he is apt to fall. He leans upon 
a stick in walking, the eyes fixed on the ground, the body thrown 
forward, and the legs wide apart. The leg is thrown out \iolently; 
the foot is raised too high and is Ijrought down with a stamping 
mo\-ement on the heel. In the arms it may be first noticed, through 
his difficulty in buttoning his collar or in other simple acts. 

With comparatively advanced ataxic symptoms he shows little 
alteration in the size, strength, or nourishment of the muscular 
system. There is, however, always present in a typical case, 
along with certain sensory disturbances, hypotonia, or lack of 
muscular tone, which allows the stretching of muscles and joints 
far beyond their normal range of movement (Frenkel). This may 
be associated with fiabbiness of the muscles, but it has no connec- 



384 EXERCISE IN EDUCATION AND MEDICINE 

tion with their actual strength, which is seldom impaired.^ The 
ataxic symptoms may be classified as — (a) Abnormally rapid 
movements; (b) exaggerated muscular exertion in performing 
simple actions; (c) prolonged contraction, continuing after the 
movement has been completed, and (d) jerky stacatto progression. 

While ataxia is the only symptom that can be reached by 
exercise, it is frequently sufficient to keep a patient bedridden 
when his other symptoms are not severe enough to interfere with 
his regular course of life. 

The exercise treatment is based on the possibility of educating 
the impaired central nervous system, and reestablishing the lost 
or enfeebled co5rdination and sensibility. The symptoms against 
which it is directed is a motor disturbance, which has its origin not 
in a diminution of the muscle's motor power, but in a loss of 
sensibility in them, and it is based on the capacity of the neuro- 
muscular system for education so long as the motor apparatus 
itself is intact. It consists in relearning the ordinary movements, 
lost in consequence of a partial or total loss of sensibility, a task 
which in principle is identical with the acquisition by a healthy 
person of a complicated feat involving a nice adjustment of mus- 
cular action, such as juggling or balancing. Reliance must then 
be placed mainly on exercises of skill, alternating with passive 
movements and massage, as a relief to improve the nourishment 
of the muscles without continuing the demand on the rapidly 
tiring will-power. 

The exercise treatment of ataxia has been popular for many 
years in Sweden, and was used forty years ago in America by 
Dr. Weir Mitchell, but many of the devices employed have been 
invented by Frenkel, of Heiden, and are for the first time described 
in his work on tabetic ataxia, from which some of the accompanying 
illustrations are taken. 

In attempting the simple movement of rising from a chair the 
tabetic patient usually forgets to draw the feet backward, and so 
finds himself unable to rise without assistance. He has thus to 
learn this simple coordination over again. 

' Frenkel, p. 46. 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 385 

Movements of walking forward, backward, and to the side, 
with steps of measured distance, should next be practised. For 
this purpose the floor may be painted with black lines or with 
foot-prints at measured distances (Fig. 337). If lines be drawn 
zigzag on the floor, their continual change of direction makes this 
walking exercise much more exacting to the patient, and an 
irregular pattern on a carpet has been used for this purpose. 




When these simple movements have been mastered, walking 
up and down stairs with the use of a bannister should be practised. 
A special stairway designed 1jy von Leyden has two bannisters, 
and the steps are cut so that the foot must be placed down accu- 
rately at each step (Fig. 338). 

The greatest precautions must be taken to prevent tlic patient 
from falling in this exercise and so becoming timid or discouraged. 
A belt with a handle or strap attachment should be placed about 



386 



EXERCISE IN EDUCATION AND MEDICINE 




Fig. 338. — Dr. von Leyden's stairway used for exercises to re-educate the lost co- 
ordination in locomotor ataxia cases (Pennsylvania Orthopaedic Institute and School 
of Mechano-Therapy (Inc.), Phila.). (Courtesy of Mr. Max J. Walter.) 




Fig. 339- 

the waist, and an attendant should always be ready to catch him 
if he shows signs of losing his balance. Exercise of the lower 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 387 

extremities can be carried on in bed, where the disease is too far 
advanced to permit of walking or standing. He is told to touch 
the great toe of one foot with the heel of the other (Fig. 339), then 




Fig. 340. 



to rim the heel upward along the front of the shin to the knee 
(Fig. 340), and back again. Another exercise is the placing of 




Fig. 341. — Notched Vjoard (Frankcl). 



the heel of either foot in notches cut in a board, as shown in the 
illustration (Fig. 341). If the ])alient be seated in front of a set 



388 



EXERCISE IN EDUCATION AND MEDICINE 



of movable pins, he can exercise by kicking them in turn, the 
attendant naming the one that he must touch with his foot (Fig. 
342). 

Simple movements such as these will cause rapid exhaustion, 
and the pulse-rate must be carefully watched, and the exercise 
stopped short of fatigue. 




Fig. 342. — Dr. von Leyden's ten-pin arrangement used for there-education of lost 
co-ordination in locomotor ataxia cases (Pennsylvania Orthopaedic Institute and School 
of Mechano-Therapy (Inc.), Phila.). (Courtesy'of Mr. Max J. Walter.) 

The upper extremity may be trained by taking a wooden 
block about eighteen inches long and triangular in section, 
so prepared that one edge remains sharp, a second beveled 
off, while the third has a curved groove. The block is placed 
on a table in front of the patient, in a position indicated by 
the drawing (Fig. 343), with the grooved edge up. He is requested 
to draw the point of a stout pencil or pointer along the groove from 
the farther end of the block toward him, at the same time holding 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 389 

his fingers and wrist-joint perfectly stiff. The object of the 
exercise is to teach him to keep his arm raised in a definite position, 
and to make simple excursions in the horizontal plane. 

This exercise is by no means easy, especially when the pencil 
has to be held with the slightest force. At first it will often leave 
the groove, but with practice its progress becomes more steady, 
although scarcely ever free from wabbling. 

It is usually a great surprise to a patient on his first exam- 
ination to find that he is unable to place his finger to his nose 




Fig. 343. — Triangle block for the hand coordination (Frenkel). 

with the eyes closed. This simple exercise may be practised and 
varied in numerous ways. Frenkel uses a perforated board 
(Fig. 344), the tip of the forefinger being placed in the numbered 
hole called out by the attendant. It can be made more difficult 
by having him insert pegs into the holes. 

When this coordination is sufiiciently improved, he may 
advance to the catching of colored balls swung from a horizontal 
bar and caught on the swing (Fig. 345); and he may be set to 
copying diagrams with a pencil. As soon as he shows signs of 



390 



EXERCISE IN EDUCATION AND MEDICINE 



flagging interest, his task should be replaced by another set of 
exercises. 




Fig. 344. — Perforated board (Frenkel). 

Along with these set exercises he should be trained in 
the useful operations of dressing and undressing himself, helping 




Fig. 345. — Colored balls swinging (Frenkel). 

himself at the table, using pen and ink, and other procedures that 
come up in the course of the day. 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 39 1 

The exercises are useful only when the attention is fully con- 
centrated on them. This necessity for concentration and the 
excessive muscular exertion required to perform simple acts, the 
fear of accidents, and the annoyance which he feels, especially at 
the beginning of the treatment because his limbs will not obey 
orders, all combine to produce rapid and profound fatigue, and 
the practice of any movement should not be continued for longer 
than three or four minutes. In severe cases, where nutrition is 
impaired, one-half to one minute will be cjuite sufficient until he 
has become strong enough to bear the strain of longer-continued 
practice and no new exercises should be begun until there is com- 
plete recovery from the excitement and fatigue of the previous one. 

Tabetic patients have more or less completely lost the sense 
of fatigue, consequently in determining whether he is tired or not 
signs of inattention and the rapid action of the heart will be the 
most reliable guides. The pulse usually rises to 120, or even to 
160, beats a minute, in direct proportion to the difficulty of the 
movement. It should be the routine practice, therefore, to 
examine the pulse at the beginning of the treatment and frequently 
throughout it, and to interrupt the work by a period of rest as soon 
as the pulse-beats exceed 150. 

The interval of rest should last until the heart-rate approaches 
normal again, although in most cases the pulse will remain a trifle 
above its usual rate. If it becomes unduly frequent after slight 
exertion, it is a sure sign of tabetic cachexia, and such patients 
must be treated with the greatest caution. 

The exercises are for coordination and not to increase the 
muscular power, therefore no exercise rec|uiring much expenditure 
of strength is of proportional value as a training in coordination, 
and so must be considered harmful. 

Two periods of exercise a day are the average rule of ])ractice. 
To go beyond that is to go into the danger zone, unless each 
seance be made short, and the patient is robust and determined 
to make rapid progress, in wliich case three periods may be given. 
In the morning he takes the movements designed for the recumljcnt 
position, which are the easiest. In the afternoon he may have flf- 



392 EXERCISE IN EDUCATION AND MEDICINE 

teen minutes of walking exercise, with frequent rests. If the 
amount be properly regulated, each successive exercise should be 
followed by an increase in control, so that at the end of a period 
he should feel more fresh and vigorous than before starting. It is 
wise in some cases to substitute for one period a general massage 
or electric treatment, which has the great advantage of resting the 
patient's will and attention and improving the nutrition. 

The unfailing certainty of the improvement and the fact that 
it is the improvement of a symptom caused by an organic lesion 
attaches unusual interest to this treatment. The hypotonia and 
sensory symptoms remain practically unaffected, although very 
frequently they seem to improve, probably because the patient's 
mind is diverted from them and directed to the acquirement of 
muscular skill; the improvement in muscular control, however^ 
may remain for years. 

The ideal result would be the restoration of the normal accuracy,, 
control, and velocity of the movements, a result which Frenkel 
claims to have achieved in many cases. The restoration in locomo- 
tion is, however, generally sufficient to enable the patient to resume 
his usual business or profession, and this is all that may be expected. 

In one case coming under my own observation, treated by 
John K. Mitchell at the Orthopaedic Hospital in Philadelphia, 
and not by any means an unusual one, a miner from California 
who came bedridden and accompanied by an attendant improved 
to such an extent that he was enabled to travel across the continent 
by himself and resume the active management of his mines. 
Such a result is so frequent as to be almost the rule. 

The improvement is more or less lasting as the patient's occupa- 
tion does or does not entail constant overstrain. If the ataxia does 
increase again, a course of exercise will once more bring it under 
control. 

In giving a forecast of the progress to be expected in 
any case the natural disposition, the alertness, and the ability 
for muscular exercise must be found out and given full weight by 
the surgeon. The more skilful patients will make more rapid 
progress, and the best results are obtained among those who have 



THE TREATMENT OF LOCOMOTOR ATAXIA BY EXERCISE 393 

been accustomed to work demanding dexterity, or who have been 
successful devotees of athletic sports, men who have lived a good 
deal in their muscles, and who have at one time had the muscular 
sense well developed. 

Another important factor is the patient's personal courage. 
Apprehensive or cowardly patients will not risk the slightest move- 
ment without support or attention, and will have to practise for 
a long time before much definite improvement can be noticed. 
The longer and more thoroughly a course is continued, the more 
certain and lasting will be the improvement, and the closer will the 
patient approach to the normal in motor capacity and accuracy 
of movements. 



INDEX 



Abdominal control, exercises for, 229 

Accidents in athletics, 190 

Activity of child, 158 

Adami on dilatation of heart, 317 

Adam's position, 282 

Age limit in games, 125 

Amherst, Dr. E. Hitchcock at, 175 

German gymnastics at, 82 

physical education at, 175 
Anatomy in jiu jitsu, 109-112 

of hernia, 363 
Anders on obesity, 346 
Anemia, exercise in, 226 
Apparatus eniplo}'ing friction, 64 

Goldthwait's, for round shoulders, 263 

gymnastic, origin of, 128 

physiological classification, 129 

Lovett's, for stretching round shoul- 
ders, 264, 265 

school furniture as, 166 

Swedish, 10 1 
Argyll-Robertson pupil in ataxia, 383 
Arnold, E. H., on games, 164 
Arterial tension, measurement of, 34 
Arteriosclerosis, causes of, 322 

definition of, 323 

diagnosis of, 324 

in Cornwall miners, 322 

Peacock on, 322 
Articulation, teaching of, 205 
Artificial respiration, 233 

Sylvester on, 261 
Astigmatism in scoliosis, Rogers on, 276 
Ataxia, Argyll-Robertson's pupil in, 383 

exercises for, 385 
treatment of, 384 

Frenkel on, 384 

John K. Mitchell on, 392 



Ataxia, prognosis of, 392 

rapid fatigue in, 391 

Romberg's symptom of, 383 

Stewart on, 383 

symptoms of, 383 
Athletes, examination of, 190 

scholarships of, 190 

Stengel on heart -murmurs in, 319 
Athletic League in N. Y. Public School, 
168 
in public school, efficiency tests in, 
170 

sports, conduct of, 190 

training, aims of, 42 
dangers of, 42 
Athletics, accidents in, 190 

class, 184 

for blind, 195 

specialization in, 189 
Automatism in exercise, 41 

Back, examination of, 254 

Balck, Colonel Victor Gustave, 91, 102 

Balfour on neuralgia, 372 

Barr, Maurice E., on mental defectives, 

214 
Bartlett gymnasium, Chicago, 175 
Basedow, 74 
Bed-posture, Brackett on, 280 

Fitz on, 280 
Beevor on tests for paralysis, 374 
Bell, Sir Charles, 20 
Benke on heart growth, 38 
Bernadotte, sympathy with Ling, 88 
Bernard, Claude, lectures of, 90 
Beveridge's rubbers, 96 
Bezly Thorne on exercise for heart, 

325-329 

395 



396 



INDEX 



Bicycling, effect on blood, 32 
Bishop, Emily, on Delsarte, 11 5-1 17 
Blake on marathon races, 320 
Blind, athletics for, 201 

compulsory exercise for, 197 

exercise for, 195 

games for, 198 

gymnasium construction for, 195 

measurements of, 195 

physical education for, 195 
limitations of, 194 

recreation for, 197 

Van de Walker on, 199 
Blood-count, J. K. Mitchell on, 227 

of athletes, 31 
Blood-pressure, Bowen on, 317 

Brunton on, 35 

during effort, 20 

effort on, 35 

exercises of endurance on, 37 

Janeway on, 35 

McCurdy on, 36 

Stephens on, 35 

variations of, 35 
Bolin, Jakob, on constipation, 362 
on examination for scoliosis, 282 
on paralysis, 376 
Bowen on blood-pressure, 317 

on pulse-rate and temperature in 
exercise, 37 
Brackett on bed-posture, 280 
Branting, 88-90 
Breathlessness, facial expression of, 23 

head poise in, 24 
Brehmer's rule, 227 
Brookline, municipal baths of, 153 

gymnasium of, 153, 156 
Brown University, German gymnastics 

at, 82 
Brunton on blood-pressure, 35 

on high tension in arteries, 323 

on muscular contraction, 31 
Burgdorf, Spiess at, 80 
Butler on deep breathing, 234 

Call, Anna Payson, on Delsarte, 115- 
117, 118 



Case-reports on scoliosis, 305 

Central Institute, founding of, 87, 90 

Chautauqua, summer school at, 191 

Chest expansion, exercises for, 228 

Cheyne, case-report of, 355 

Chiasso, Captain, on polymachinon, 56, 

57 
Chicago University, physical education 

at, 176 
Child, normal activity of, 158 
Chorea, 380 

treatment of, 381 
Circulation, influence of games on, 126, 

127 
City homes, condition of, 140 
Clark, E. E., on falsetto voice, 380 
Class work, exhilaration from, 130 

progression in, 189 
Cliff ord-Al butt on heart-strain, 319 
College gymnasium, equipment of, 185 

life, physical effects of, 181 

of City of New York, physical educa- 
tion at, 176 

yearly course in exercise, 186 
Columbia University, summer school at, 

191 
Concentration of attention, 21 
Conditioning, effects on fatigue, 33 
Constipation, Bolin on, 362 

exercise for, 361 

frequency of, 360 

massage in, 226 

Zander on, 362 
Copenhagen, 75 

Cornwall miners, arteriosclerosis in, 322 
Correspondence schools of exercise, 1 19 
advantages of, 120 
dangers of, 121 
Crime, juvenile, 138 
Criminals, characteristics of, 217-220 

Wey on, 220 
Curtain ball, Sargent's, 128 
Curves of normal spine, 250 

Daily exercise, Gulick on, 134 

set of free exercises, 134 
Darmstadt normal school, 80 



INDEX 



397 



Darwin, 20 

Day's order, Ling's, 93 

origin of, 91 
Deaf-mutes, balance movements for, 207 

exercise for, 206 

games for, 209 

longevity of, 208 

measurements of, 205-209 

physical peculiarities of, 205 
Deep breathing, Butler on, 234 

exercises for, 228 
Deformed scapula, Goldthwait on, 266 
Deformities of foot, 236 
Delinquents, military drill for, 217 

physical education for, 217 
Delsarte, Anna Payson Call on, 115, 117, 
118 

Bishop on, 115-117 

Geraldy on, 115 

Giraudet on, 115 

life of, 114, 115 

Stebbins on, 115-117 

sayings of, 115 

Steele Mackaye on, 115 

system of, 115 
Dessau, 74 
Developing apparatus, Goldie's, 62 

Sargent's, 60, 61 
Diabetes, exercise for, 357 

Finkler on, 357 
Diagnosis of arterioscleriosis, 324 

of flat-foot, 242 
Dilatation of heart, 317 

Roy and Adami on, 317 
Du Bois-Reymond, 81 
Dullards, improvement of, 221 

physical training for, 220 
Dumb-bell, Sandow's spring, 118, 119 
Dumb-bells used by Greeks, 57 
Dyspepsia, exercise in, 360 

nervous Weir Mitchell on, 360 

Eberhart on vibrators, 71 
Eccles on massage in sciatica, 371 

on neuralgia, 372 
Edinger's theory of locomotor ataxia, 

382 



Education of immigrants by playgrounds, 

140 
Effleurage, description of, 50 
Effort, blood-pressure during, 20 

economy in, 39 

effect on muscles, 21, 22 

exercises of, 18 

muscle rupture from, 30 

on blood-pressure, 35 

qualities cultivated by, 21 
Elmira State Penitentiary, 220 
Emerson, C. W., exercises of, 118 
Endurance, exercises of, 18 
Enebuske, Claes, 93 
Equipment of college gymnasium, 185 

of large playground, 150 

of school gymnasiums, 167 

of small playground, 142 
Erector spinae, action of, 297 
Evolution in play, 124 
Examination for scoliosis, 282 
Bolin on, 282 

of athletes, 190 

of back, 254 

of fiat-foot, 241 

of obesity, 348 

physical, of students, 176 
Exercise, active, 17 

automatism in, 41 

class credit for, 181 

correspondence schools of, 119 

daily, Gulick on, 134 

definition of, 17 

for ataxia, 385, 389 

for blind, 195, 197 

for constipation, 361 

for deaf-mutes, 206 

for diabetes, 357 

for gout, 356 

for heart, Bezly Thorne on, 325-329 
Heineman on, 325-345 
weakness, 225 

for hernia, 366 

for scoliosis, 294 

for sedentary occupations, 134 

for tuberculosis, 227 

free, daily set of, 134 



398 



INDEX 



Exercise in anemia, 226 

in college, Benjamin Franklin on, 174 

Jefferson on, 174 
in dyspepsia, 360 
in gastritis, 359 
in morning, 134 
in old age, 130 

in pathological conditions, 222 
instruction in theory of, 191 
of endurance for gout, 226 
passive, 17, 27 

effects of, 28 

in fatigue, 27 

on atrophy, 31 
periods in school, 164 
prescription for scoliosis, 300 
tonic effect of, 226 
yearly course, in college, 186 
Exercises for abdominal control, 229 
for chest expansion, 228 
for flat-foot, 292 
for heart, Satterthwaite on, 343 
for nervous diseases, 226 
for obesity, 352 
for round shoulders, 257 
gymnastic, physiological classification, 

129 
of deep breathing, 228 
of effort, 18 
of endurance, 18 

description of, 22 

effects of, 31 

excess in, 22 

fatigue products in, 22 

on blood-pressure, 37 

on heart, 38 

qualities cultivated by, 22 
of skill, 18 
school, 81 
Exhaustion, 26 

from alertness, 40 
Expectation of life, Farr's tables on, 321 
Eye examinations of students, 179 

Facial expression as index, 21 
of breathlessness, 23 
of effort, 19 



Facial expression of fatigue, 24 
of rage, 20 
of strain, 20 
Fahrner on fatigue at school, 279 
Farr's tables of expectation of life, 321 
Fatal touch, Japanese 107 
Fatigue, acute, 23, 33 

chronic, 26 

facial expression of, 24 

fever, 44 

general, 24 
effects of, 25 

in ataxia, 391 

massage in, 49, 223 

passive exercises for, 27 

poise of head in, 25 

products, intoxication by, 41 
Lee on, 43 

relative, 39 

scoliosis of, 278 

subacute, 26 

temperature in, 26 
Faulty attitude, varieties of, 252 
Feeblemindedness, physical signs of, 210 
Fellenberg, 74 
Fernald, 21 1-2 13 
Finkler on diabetes, 357 
Finsen, 75, 76 
Fitz, George W., on round shoulders, 255 

on bed-posture in scoliosis, 280 

on round shoulders, 263 

method of measurement in scoliosis, 
283 
Flat-foot, cause of, 238 

diagnosis of, 242 

examination of, 241 

exercises for, 242 

frequency of, 240 

Ochsner's bandage for, 248 

record of, 241 

Roth on, 246 

shoe for, 246 

symptoms of, 239, 240 

treatment of, 242 

Whitman's foot-plate for, 247 
Folk-dancing in playgrounds, 152 
Follen at Harvard, 82, 175 



INDEX 



399 



Food and muscular waste, 41 
Foot, deformities of, 236 

lateral arch of, 238 

structure of, 236 
Foot-ball players, weight of, 180 
Frankfort, turnfest at, 79 
Franklin, Benjamin, on exercise in col- 
lege, 174 

Field, 184 
Frenkel on ataxia, 384 
Friction, description of, 51 
Froebel, 80, 124 

Galen on massage, 30 
Games, age limit in, 125 

classification of, 126, 127 

collections of, 164 

for blind, 198 

for deaf-mutes, 209 

gymnastic, 128 

in recess, 163 

influence on circulation, 126, 127 

muscles used in, 126, 127 

nerve control required in, 126, 127 

popularity of children's, 122 

therapeutic effects of, 128 
Gang instinct in boys, 1 23 
Garber's adjustable desk, 160 
Garland, 152 
Gastritis, exercise in, 359 

massage in, 226 
Georgii, 88-90 
Geraldy on Delsarte, 115 
German gymnastics, first manual of, 75 
in America, 82 

system, history of, ,74 
peculiarities of, 84 
Stecher's classification, 83 
Giessen, Spiess' work at, 80 
Giraudet on Delsarte, 115 
Glen Mills, school at, 218, 219 
Goldie's exerciser, 62 
Goldthwait on deformerl scajjula, 266 

on round shoulders, 255, 256 
Goldthwait's apparatus for round shoul- 
ders, 263 
Gould on causation of scoliosis, 275-277 



Gould on writing position, 292 
Gout, exercise for, 356 

treatment of, 226 
Graham, Douglas, on rheumatism, 358 

on sciatica, 371 
Granville J. Mortimer's theory of pain, 

372 
Granville's percutor, 372 
Green, Grace, 208 

on deaf girls, 205 
Greenwood on normal posture, 252 
Gulick on athletic league, 168 

on daily exercise, 134 

on games, 122, 123 

on play traditions, 164 
Guts-Muths, 74, 75, 80 
Gymnasium construction for blind, 195 

first public, 82 
Gymnasium-school, ec[uipment of, 167 
Gymnastic apparatus, classification of, 
129 

for mental defectives, 212 

formal, in child-training, 124 

in playgrounds, 150 

institute in Berlin, 81 

lesson, arrangement of, 130 

medical, beginnings of, 88 

school, beginnings of, 88 

Swedish medical, 103 

Hartelius, 90 

Hartwell, 93 

Harvard, Follen at, 175 

Hawk on blood-count, 31 

Heart, Bezly Thorne on exercise for, 325- 

329 
dilatation of, 317 
diseases of, 315 

action of exercise in, 325 

Wide on massage for, 325 
exercises of endurance on, 38 

Satterthwaile on, 343 
growth, Benke on, 38 
Hcineman on exercise for, 325-345 
murmurs in athletes, Stengel on, 319 
of oarsmen, 320 
overstrain of, 317 



400 



INDEX 



Heart, prognosis of exercise treatment 
for, 345 

strain, Cliff ord-Albutt on, 319 
Schott on, 317 

valvular defects of, 315 

weakness, exercise for, 225 
Heat, regulation of, 29, 30 
Heineman on heart exercise, 325-345 
Hemenway Gymnasium, 175 

Mrs. Mary, 92 
Henry, Admiral, case-report of, 359 
Hermann, rout of, 76 
Hernia, 362 

anatomy of, 363 

diagnosis of, 363 

exercise for, 366 

Seaver's truss for, 365 

support for, 365 
High tension, Brunton on, 323 
Hippocrates on conditioning, 44 
Hitchcock at Amherst, 175 

on measurements, 191 
Hokusai, sketches of, 105 
Homans, Miss Amy M., 93 
Hooker at Amherst, 175 
Horizontal bar controversy, 8i 

Ideal college athlete, 193 
Indianapolis, college at, 82 
Inomotor, Sargent's, 64 
Intoxication of fatigue-products, 41 

Jahn, 74-77, 80 

Janeway on blood-pressure, 35 

Jefferson on exercise in college, 174 

Jiu jitsu, dangers of, 113 

introduction in America, 108 
knowledge of anatomy in, 109-112 
modifications of, 108 
O'Brien on, 108, in, 113 
origin of, 104 
secrets of, 106 

Jiudo, 104 

Juggling, physiology of, 21 

Kano school in Tokyo, 108 
Keynote position, Roth's, 282, 295 



Kidneys, action of, in elimination, 44 
Kindergarten, games of, 161 
Kinghorn on phthisis, 227 
Kitson, H. H,, 192 
Kuatsu, art of, 104, 106, 107 

Lagrange, 328 

Larabee on Marathon runners, 320 

Latent period, 30 

Lee, F. S., on fatigue-products, 43 

J- E., 137 
Lefebure on day's order, loi 
Lever, principle of, 69 
Lieber, 77-82 
Liedbeck, 88 
Ling, Hjalmar Frederick, 90 

honors awarded to, 88 

literary activity of, 87, 88 

on massage, 46 

Peter Henry, 74, 81, 86 
life of, 86 

physiology of, 89 
Lip reading, teaching of, 206 
Locomotor ataxia, definition of, 382 

Edinger's theory of, 382 
Lombard on weight loss, 42, 43 
Longevity of oarsmen, Meylan on, 321 
Lovett's apparatus in round shoulders, 
261, 265 

measurement of round shoulders, 251 
Lund, University of, 86, 87 
Lung capacity, rapid increase of, 312 

Macdonald Smith on full contraction, 

117, 118 
Machine, McKenzie's, for scoliosis 

measurement, 284, 285 
Maggiora, experiment of, on massage, 

47-49 
Makuen on artistic breathing, 3 78 
Marathon race, 44 

Blake and Larabee on, 320 
Mason, J. L., 154-156 
Massage, action on muscles, 47 

as stimulant, 222 

automatic, 39 

classification of, 5'" 



INDEX 



401 



Massage, definition of, 45 

derivation of, 45 

duration of, 55 

effects of, 38 

for fatigue, 49 

for heart disease. Wide, 325 

for muscle wasting, 31 

for obesity, 225 

for rheumatism, 35S 

general, 54 

history of, 45 

for constipation, 226 

for fatigue, 222 

for gastritis, 226 

in Greece, 45 

in Japan, 45 

on nervous system, 41 

for neuritis, 371 

for obesity, 352 

for rheumatism, 226, 358 

for sciatica, 371 

for sprains, 222 

Ling on, 46 

Maggiora's experiments on, 47-49 

mechanical effects of, 49 

Mezgar on, 46 

precautions in, 55 

requirements of, 46 
McCurdy on blood-pressure, 36 
McKenzie's machine for measurement 

of scoliosis, 284, 285 
Measurement, Fitz's method, in scoliosis, 

283 
McKenzie's method in scoliosis, 284, 

283 
of blind, 195 
of deaf-mutes, ^05-209 
Roth's method, in scoliosis, 283 
Schulthess' machine for, 283, 284 
Spellissy's method, in scoliosis, 283 
Mechanotherapy in America, 71 
Medical gymnastics, supervision in, 235 

Swedish, 103 
Melville Bell on stammering, 378 
Mental defectives, Barr on, 214 
diagnosis for, 212 
gymnastics for, 212 
26 



Mental defectives, habits of, 211 
management of, 211 
military drill for, 214 
proportions of, 210 
schools for, 212 
Tadd on, 216 
Warner on, 211 
Meylan, Geo. L., 157 

on longevity of oarsmen, 321 
Mezgar on massage, 46 
Military drill for delinquents, 217 
for mental defectives, 214 
gymnastics, Swedish, 94 
Mind and body, 83 
Mitchell on ataxia, 392 

on blood changes from massage, 32 
on blood-count, 227 
Montrichard, 86 

Morgan on survival of oarsmen, 321 
Mosher on standing posture, 165 
Mosso's plethysmograph, 31, 32 
Mount Airy, 208 

institution for deaf-mutes, 206 
Movements, automatic, 39 
brain, control of, 39 
necessity for natural, 40 
spontaneous, in infants, 122 
Muller on fifteen minutes daily exercise, 

134 
Murray, 91 

Muscles, action of massage on, 47 
of spine, 271 
overdevelopment of, 22 
ruptured, cause of, 30 

from effort, 30 
soreness, cause of, 29 
tonus, 29 

used in games, 126, 127 
Muscle-wasting, massage for, 31 
Muscular action, isolation in treatment 
of scoliosis, 296 
contraction, Brunton on, 31 
descri])tion of, 29 
effects of, 2g 

Nachtkcaij,, 74, 75, 86, 87 
Nephritis from fatigue, 44 



402 



INDEX 



Nervous diseases, exercises for, 226 
dyspepsia. Weir Mitchell on, 360 

Neuralgia, Balfour on, 372 
Eccles on, 372 

Neurasthenia, treatment of, 376 
Weir Mitchell on, 376 

Neuritis, massage in, 371 

Neuroses of occupation, 372 
treatment of, 373 

New York City, overcrowding in, 137 

Newark Athletic League, 173 

Newton on blood-pressure, 35 

Nibecker, 221 

Nissen, 92 

Nyblaeus, Col. Gustave, 90 

Oarsmen, hearts of, 320 

Meylan on longevity of, 321 

Morgan on survival of, 321 

mortality of, 321 

weight of, 180 
Obesity, causes of, 346 

complications of, 349 

degrees of, 398 

diet in, 351 

examination of, 348 

exercises for, 352 
Anders on, 346 

local, 346 

massage in, 225 

prognosis in, 348, 355 

rapid reduction of, 352 

reduction cures for, 350 

thyroid extract in, 354 

treatment of, 225 

Von Noorden on massage for, 352 
O'Brien, J. J., on jiu jitsu, 108, iii, 113 
Occupation disorders, 225 

evil effects of, 133 

neuroses of, 373 
Ochsner's bandage for flat-foot, 248 
Oertel's cure, 325, 326 
at Reichenhall, 328 
limitations of, 328 

experiments, 327 
Old age, exercise in, 130 
Orton, George, 157 



Overcrowding in New York City, 137 ' 
Overtraining, effects of, 26 



Pain organ, 73 
Pantograph, tracings by, 253 
Parallel bars controversy, 81 
Paralysis, Beevor's tests for, 374 

Bolin on, 376 

infantile, 373 

regions involved, 374 

prognosis of, 376 

treatment of, 376 
Pathological conditions, exercise in, 222 
Peacock on arteriosclerosis, 322 
Pelvic girdle, structure of, 250 
Pentathlon, 74 
Percussion, 52 
Percutor, Granville's, 372 
Pestalozzi, 79, 80 
Petrissage, description of, 52 
Philadelphia Playgrounds Association, 

173 
Philanthropinum, 74 
Phillips on sprinters, 192 
Phthisis, Kinghorn on, 227 
Physical education at Amherst, 175 
at Chicago University, 176 
at College of New York, 1 76 
at Harvard, 175 

at University of Pennsylvania, 176 
for blind, 195 

fundamental principles of, 182 
research in, 191 
ideal, 193 

intelligence, value of, 182 
limitations of blind, 194 
peculiarities of deaf-mutes, 205 
training for delinquents, 217 
for dulness, 220 
Physiological load, law of, 57 
Piano playing, 21 
Pilgrim on vibration, 71-73 
Platysma, action of, 19, 20 
Play, evolution in; 124 
Playground Association, American, 82 
German, 82 



INDEX 



403 



►Playground Committee, New York, 
work of, 137 
effect on emigrants, 140 
equipment of, large, 150 
private house, 143 
small, 142 
folk-dancing in, 152 
gymnastics in, 150 
how founded, 140 

plan of, 148 
Philadelphia, 173 
public school, 144, 147, 152 
roof, 167 

rouiid games in, 152 
supervision of, 150 
swimming in, 152 
types of, 141 
Plethysmograph, Mosso's, 31, 32 
Polymachinon, Chiosso's, 56, 57 
Posse, 91-93 

gymnasium, 93 
Posture, correct sitting, 161 
standing, 165 
defects of, 225 
exercise for, 224 
faulty, varieties of, 252 
in school, 160 

normal. Greenwood on, 252 
standing, change of spine in, 250 
Mosher on, 165 
Roberts on, 259 
spinal curve in, 250 
Presence of mind, 40 
Prognosis in ataxia, 392 

in exercise treatment for heart, 

345 
in obesity, 348, 355 
in paralysis, 376 
in round shoulders, 256 
Prolongation of life, Weber on, 131 
Psoas, isolation of, 296 
Public School Athletic League, girl's 
branch, 172 
grounds f)f, 172 
Pulley-weights, dangers of, 63 
description of, 58-62 
limitations of, 63 



Pulley-weights, principle of, 57, 58 
Pulse-rate in exercise, Bowen on, 37 
Zander on reducing, 325 

Quarter CIRCLE, 59, 60 

Rage, facial expression of, 20 
Record of flat-foot, 241 
Reichenhall, Oertell's cure at, 328 
Research in physical education, 191 
Respiration, artificial, 233 

Japanese, 107 
chemistry of, 33 
Rheumatism, Douglas Graham on, 358 
massage in, 226, 358 
vibration for, 358 
Rifle shooting in schools, 1 70 
Riva-Rocci sphygmomanometer, 35 
Roberts on standing posture, 259 
Rogers on astigmatism in scoliosis, 276 
Romberg's symptom of ataxia, 383 
Roth, Bernard, 90 

on flat-foot, 240 

on method of measurement in 
scoliosis, 283 
Matthias, 90 
Roth's keynote position, 282-295 
Rothstein, 81, 89 
Round back, tracings of, 253 
shoulders, causes of, 254 

definition of, 251 

diagnosis of, 256 

exercises for, 257 

Fitz on, 255, 263 

frequency of, 255 

Goldthwait on, 255, 256 

Goldthwait's apparatus for, 263 

Lovett's apparatus for, 264, 265 
measurement of, 251 

prognosis of, 256 

treatment of, 256 

Zander's tower for, 262 
Rousseau, 74 
Roy and Adami on dilatation of heart. 

317 
Running, change of pace in, 27 
long-distance, 26 



404 



INDEX 



Salzman, 74 

Samauri, order of, 104, 105 

Sandow's spring dumb-bell, 118, 119 

Sandpile, care of, 144 

Sargent, Dudley A., at Harvard, 175 

on curtain ball, 128 

on developing apparatus, 60, 61 

on inomotor, 64 

on measurements, 191, 193 

on pulley weights, 57-61 
Satterthwaite's exercises for heart, 343 
Sayre's sling, 304 
Schnepfenthal, school of, 74 
Schoolboys, examination of, 173 
School, rules for construction of desk, 

293 

for mental defectives, 212 

furniture, adjustable, 159 
as apparatus, 166 
rules for, 159 

gymnasium, equipment of, 167 

house, construction of, 158 

life and scoliosis, 279 

posture in, 160 

recess, 163 

room, graded work in, 165 

lighting of, 294 

fatigue, Fahrner on, 279 

seating, Scudder on, 158 
Schott on heart-strain, 317 

treatment at Bad Nauheim, 328 
description of, 328 
Schulthess' machine for measurement of 

scoliosis, 283, 284 
Schwanenrede, Jahn's, 77 
Schwann's law of muscular contraction, 

69 

Sciatica, Eccles on massage for, 371 

Graham on, 371 

vibration for, 371 
Scoliosis and school -life, 279 

bed-posture in, 280 

Bolin on examination, 282 

case-reports, 305 

causes of, 275 

development of thorax in, 312 

diagnosis of, 286 



Scoliosis, examination for, 282 

exercise for, 294 

experimental, 281 

Fitz's method of measurement, 283 

frequency of, 274 

Gould on causation of, 275-277 

isolation of muscular action in treat- 
ment of, 296 

measurement of, 283 

of fatigue, 278 

prescription of exercise for, 300 

prognosis of, 290 

Roth's method for measurement of, 
283 

Roger's on astigmatism in, 276 

Schulthess' machine for measurement, 
283, 284 

Spellissy's method of measurement, 
283 

symptoms of, 289 

treatment of, 291 

varieties of, 288 
Scudder on school seating, 158 
Seaver on measurements, 191 
Seaver's truss for hernia, 365 
Second wind, 24 

Sedentary occupations, exercise for, 134 
Self -massage on nutrition, 31 
Sex, in play, 124 
Shaking, description of, 53 
Shaw on school day, 161 
Shoulder-girdle, structure of, 250 
Shoulders, forward displacement of, 253 

uneven, 266 
causes of, 267 
prognosis of, 270 
treatment of, 267 
Sillow, 91 

Singing with gymnastics, 81 
Skill, exercises of, 18 

progression in, 40 
Small shoe for fiat-foot, 246 
Social center, Chicago, 150 
Speech, mechanism of, 378 
Speed-skaters, measurements of, 193 
Spellissy's photographic method for 

measurement in scoliosis, 283 



INDEX 



405 



Sphygmomanometer, Stanton's, 34 

Spiess, 74-So 

Spinal assistant, Taylor's, 262, 264 

curve change in standing posture, 250 
Spine, infantile, shape of, 250 

movements of, 272 

muscles of, 271 

normal, curves of, 250 
Sporting Times, founding of, 91 
Sports, analysis for class use, 1S5 
Sprains, massage in, 222 
Sprinters, Phillips on, 192 
Stagg on weight reduction, 352 
Stairway, Von Leyden's, 385, 386 
Staleness, 22, 41 
Stammering, 377 

Bell on, 378 

frequency of, 378 

treatment of, 379 
Standing attitude, normal, 251, 252 
Stanton's sphygmomanometer, 34 
Starr Garden Playground, plan of, 147 
Stebbens on Delsarte, 115-117 
Stecher, Wm. A., 83 
Steele Mackaye on Delsarte, 115 
Stengel, heart-murmurs in athletes, 319 
Stephens on blood-pressure, 35 
Stewart on ataxia, 383 
Stokes, 325, 326 
Strain, facial expression of, 20 
Striking, 52 

Stroking, description of, 50 
Students, eye examinations of, 179 

physical defects in, 177 
excess of, 176 
Subtarget machine, 170 
Summer camps for city children, 157 
Y. M. C. A., 157 

schools, 191 

at Chatauqua, 191 
at College of City of New York, 191 
Supervision in medical gymnastics, 235 
Sylvester on artificial respiration, 261 
Symptoms of flat-foot, 239, 240 
Swedish apparatus, loi 

gymnastics introduced in United 
States, 91 



Sweedish gymnastics, limitations of, 

lOI 

military, 94 
medical gymhastics, 103 
system, characteristics of, 94 
Swimming in playgrounds, 152 

Tadd on drawing for defectives, 216 
Tapotement, description of, 52 
Taylor on developing apparatus, 70 
Taylor's " spinal assistant," 262, 264 
Techow, 89 
Temperature during exercise, Bowen on, 

37 

rise of, in muscular action, 29 
Tendon, strain of, 30 
Therapeutic effects of games, 1 28 
Thorax, torsion of, 299 
Thyroid extract in obesity, 354 
" Tidschrift i Gymnastics, " 90 
Torngren, 91 

Tournaments, dates of, 76 
Treatment of round shoulders, 256 

of scoliosis, 291 

of uneven shoulders, 270 
Tremble-pressing, description of, 54 
Tuberculosis, exercise for, 227 
Turnfest at Frankfort, 79 
Turngemeinden in America, 82 
Turning in German Universities, 76 
Turnkunst, badge of, 76 
Turnplatz, first, 75 
Turnvereine, descriptions of, 79 

University oars, Morgan on, 321 
of Pennsylvania, 31, 42 
physical education at, 176 
Urbinization of population, 132 

Valvular defects of heart, 315 
Van de Walker on the blind, 199 
Vibration, 53 

application of, 71 

for rheumatism, 358 

for sciatica, 371 

Pilgrim on, 71-73 

theory of, 73 



4o6 



INDEX 



Vibrators, Eberhart on, 71 

modifications of, 70 

Zander's, 70 
Virchow, 81 

Von Leyden's stairway, 385, 386 
Von Noorden, 225 

on massage in obesity, 352 
Von Schenkendorff, 82 

Wading pool, 152 
Walking, rate of, 124, 125 
Warner on mental defectives, 211 
Washington Gardens, gymnasium at, 82 
Water-polo, effect on blood, 32 
Weber on prolongation of life, 131 
Weight, loss of, 42 

Lombard on, 42, 43 
of foot-ball players, 180 
of oarsmen, 180 
reduction, dangers of, 355 

Stagg on, 352 
Weir Mitchell, 31, 55 

on nervous dsypepsia, 360 

on neurasthenia, 376 



Wellesley and Boston Normal School, 93 
Wey on criminals, 220 
Wide on massage for heart disease, 32 ^ 
Williams College, 142 

German gymnastics at, 82 
Whitman's foot-plate for flat-foot, 247 
Witmer on pain organ, 73, 370 
Writing position, 160 

Gould's, 292 



Yale University, 

at, 82 
Yoshin-Riu, 104 



German gymnastics 



Zander, 17, 54 

history of, 66 

institutes, 66 

machines, 66-70 
advantages of, 70 

on constipation, 362 

on reducing pulse -rate, 325 
Zander's tower, 234 

for round shoulders, 262 

vibrator, 70 



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